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IS^tfnmct  ilibrarg 


A 

PRACTICAL  TREATISE 

ON 

Neea^ous  Exhaustion 

(NEURASTHENIA) 

ITS 

Symptoms,  Xature,  Sequences,  'I'l'catmeiit 

BY 

GEORGE  M.    BEARD,    A.M.,   M  D. 

FELLOW    l)F    THE   NKW    YORK    A(rADEMY    OF  MEDICINE  ;    OK  THE   NEW   YORK   ACADEMY   OF 
BCIENCES;    VICE-PRESIDENT  OF  THE  AMERICAN   ACADEMY   OF  MEDICINE;    MEMBER 
OF  THE  AMERICAN  NECKOLOOICAL  ASSOCIATION;   OF  THE  AtlERICAN   MEDI- 
CAL association;  THE  NEW  YORK  NKUROLOOICAL  SOCIETY,  ETC. 

KDITKD.   AVITII   NOTES  AND  ADDITIONS, 

BY 

A.    \).    ROCKWELL,    A.M.,   M.D. 

PROFESSOR   OF   ELECTRO  THERAPECTICH    IN    THE    NEW   YORK    POST    GRADl'ATE    MEDICAL 

SCHOOL  AND   HOSPITAL;    FELLOW  OF  THE   NEW   YORK   ACADEMY;    MEMBER    liF 

THE   AMERICAN    NKlHOUMilCAL   ASSOCIATION;    OF  THE   NEW 

YORK    NEl'KUlAKilCAI.   S<J<:IETV.    ETC. 


NEW  YORK 
E.  B.  TREAT,  771  BROADWAY 


1«89 
c  Price  $2.75 


OOPYRIGHT 

Py  e.  b  treat 

1888. 


THE  PCBLISHERS'   PRINTING  COMPANY 

157  &   150  WILLIAM  ST. 

NEW  YORK 


EDITOR'S  PREFACE. 


Neurasthenia  is  now  almost  a  household  word,  and, 
equally  with  the  term  malaria,  affords  to  the  profes- 
sion a  convenient  refuge  when  perplexed  at  the  recital 
of  a  multitude  of  symptoms  seemingly  without  logical 
connection  or  adequate  cause.  [The  diagnosis  of  neu- 
rasthenia, moreover,  is  often  as  satisfactory  to  the 
patient  as  it  is  easy  to  the  physician,  and  by  no  means 
helps  to  reduce  the  number  who  have  been  duly  cer- 
tified to  as  neurasthenic,  and  who  ever  after,  with  an 
air  too  conscious  to  be  concealed,  allude  to  themselves 
as  the  victims  of  nervous  exhaustion.  The  doctiine  to 
be  taught  and  strongly  enforced  is  that  many  of  these 
patients  are  not  neurasthenic,  and  under  hardly  any 
conceivable  circumstance  could  they  become  neui'as- 
thenic.  They  do  not  belong  to  the  type  out  of  which 
neurasthenia  is  born,  either  mentally  or  physically. 

Many  of  them  are  unintellectual,  phlegmatic,  and 
intolerably  indolent,  and  are  jileased  at  a  diagnosis 
which  touches  the  nerves  ratlier  than  the  stomach, 
bowels,  and  liver.  Instead,  therefore,  of  rest,  quiet, 
and  soothing  draughts,  they  need  mental  and  physi- 
cal activity,  less  rather  than  more  food,  depletion 
rather  than  repletion.] 

These  patients  are  litha^mic  and  not  neurasthenic. ' 


4:  editor's  preface. 

The  nervous  system  is  strong  enough,  and  would  give 
no  trouble  were  it  not  poisoned  by  the  abnormal  prod- 
ucts of  digestion  that  enter  the  blood  and  circulate 
freely  through  every  tissue  of  the  body.  Now,  while 
protesting  against  the  too  indiscriminate  diagnosis  of 
neurastheuia,  Iwould  by  no  means  have  it  understood 
that  I  am  not  a  firm  believer  in  the  propriety  of  clas- 
sifying under  this  head  that  great  family  of  symptoms 
which  the  late  Di*.  Beard  was  the  first  to  distinctly 
formulate  and  label.  In  many  cases  it  is  true,  the 
neurotic  and  the  hepatic  types  are  so  combined  in  the 
same  individual  as  to  give  rise  to  the  expressive  term 
neurasthenic  lithaemia,  but  in  other  cases,  the  symp- 
toms, while  in  many  respects  similar,  depend  upon  en- 
tirely different  causes,  and  justify  a  distinct  nomencla- 
ture. Dr.  Beard  quite  overlooked  this  important  point 
in  the  present  Avork,  although  in  "Sexual  Neurasthe- 
nia," the  MSS.  of  which  he  left  unfinished,  but  which 
I  completed  and  edited  some  years  ago,  the  subject  is 
simply  alluded  to. 

In  reissuing  this  book  I  have,  besides  various  other 
additions,  called  attention  to  some  of  the  differential 
points  of  diagnosis  between  neurasthenia  and  that 
functional  disturbance  of  the  digestive  system  that  we 
term  lithaemia,  tAvo  conditions  demanding  methods  of 
treatraeut  radically  diverse. 

The  editor's  notes  and  additions  are  indicated  by 
brackets  [  ],  pages  85  to  87;  138  to  146;  207  to  212;  236 
to  238  and  sundry  foot  notes.  A.  D.  Eockwell. 

113  West  34th  Street, 

Oct.  15th,  1888. 


PREFACE. 


In  this  country  nervous  exhaustion  (neurasthenia) 
is  more  common  than  any  other  form  of  nervous  dis- 
ease. With  the  various  neuroses  to  which  it  is  allied, 
and  to  which  it  leads,  it  constitutes  a  family  of  func- 
tional disorders  that  are  of  compamtively  recent  de- 
velopment, and  that  abound  especially  in  the  northern 
and  eastern  part  of  the  United  States. 

In  spite  of  its  frequency  and  importance,  nem*asthe- 
nia,  although  long  recognized,  in  a  vague  way,  among 
the  people  and  the  profession  under  such  terms  as 
"general  debility,"  "  nervous  prostration,"  "nervous 
debiUty,"  "  nen^ous  asthenia,"  "spinal  weakness," 
and,  more  accurately,  by  some  of  its  special  symptoms 
and  accompaniments,  as  "  spinal  initation,"  "  nervous 
dyspepsia,"  "oxaluiia,"  cerebral  and  spinal  anaemia 
and  hypeiaemia,  is  even  now  but  just  beginning  to  find 
recognition  hi  the  hterature  of  nervous  diseases.  It  is 
at  once  the  most  frequent,  most  interesting,  and  most 
neglected  nervous  disease  of  modem  times. 

Among  specialists  and  general  pmctitioners  alike, 
there  has  been,  on  this  whole  subject,  a  fearful  and 
wondrous  confusion  of  ideas.  These  functiona  Inei-vous 
symptoms  have,  in  shoil;,  always  slipped  from  our 


6  PREFACE. 

grasp  whenever  we  have  attempted  to  seize  them  and 
bring  them  into  science;  and  in  discouragement  and 
disgust,  and  in  a  spirit  of  skepticism,  which  is  the 
highest  form  of  creduhty,  physicians,  imitating  the 
unscientific  example  of  the  laity,  have  denied  the  ex- 
istence of  such  symptoms,  just  as  they  formerly  denied 
the  existence  of  diphtheria  and  hay  fever.  Neuras- 
thenia, indeed,  has  been  the  Central  Africa  of  medicine 
— an  unexplored  territory  into  which  few  men  enter, 
and  those  few  have  been  compelled  to  bring  reports 
that  have  been  neither  credited  nor  comprehended. 

The  present  work  is  the  result  of  the  experience  and 
study  of  my  entire  professional  life  in  the  subject  to 
which  it  relates. 

The  term  neurasthenia  (nervous  exhaustion)  is  of 
Greek  derivation  [•:'£T>p<>v  nerve,  «  privative,  and  ffSevo^ 
strength],  and  literally  interpreted  means  lack  of  nei^ve 
strength. 

My  first  paper  on  this  subject,  based  on  the  study  of 
thirty  cases,  was  prepared  in  1868,  was  read  before 
the  New  York  Medical  Journal  Association,  and  was 
published  in  the  Boston  Medical  and  Surgical  Jour- 
nal, April  29th,  1869,  and  subsequently  appeared  in  the 
first  edition  of  Beard  and  Rockwell's  "  Electricity." 
This  was,  so  far  as  I  know,  the  first  systematic  treat- 
ise on  neurasthenia  ever  pubhshed. 

At  first  the  subject  excited  absolutely  no  interest  in 
the  profession  of  this  country. 

In  Europe  the  effect  was  somewhat  different.  In 
England,  Dr.  Hugh  CampbeU  shortly  after  published 


PREFACE.  "        y 

a  work  on  Nervous  Exhaustion,  largely,  if  not  entirely, 
based  on  my  writings  on  that  subject,  and  containing 
little  additional  matter;  it  was  clear  that,  although  in- 
terested in  this  functional  nervous  disease,  his  oppor- 
tunities for  observation  had  not  been  abundant,  and 
that  he  was  not  fully  capable  of  analyzing  and  formu- 
lating his  o^vn  material.  In  England,  his  work  has 
passed  through  many  editions.  In  Germany,  how- 
ever, where  the  above-mentioned  work  on  Electricity 
became  widely  known  through  the  translation  of 
Vater,  of  the  University  of  Prague,  that  section  of  it 
devoted  to  neurasthenia  met,  for  the  first  time,  with 
a  criticism  and  comment  at  once  sympathetic,  intelli- 
gent, and  scientific. 

In  the  volume  of  Ziemssen's  "Cyclopaedia"  that 
treats  of  diseases  of  the  spinal  cord,  which  was  pre-/  y^ 
pared  by  Professor  Erb,  of  Heidelberg,  one  of  the  very 
ablest  of  tlje  Gei-man  neurologists,  and  one  of  the  most 
oiiginal  and  i)hilosophical  of  recent  medical  writere,  is 
found  a  chapter  on  spinal  exhaustion,  wherein  he  not 
only  confirms  the  description  and  analysis  and  nomen- 
clature of  neurastlienia  which  I  gave  several  years  ago, 
but  adds  some  judicious  and  valuable  observations  of 
his  own.  Erb,  after  giving  a  correct  atialysis,  in  a 
very  general  way,  of  some  of  the  more  prominent 
symptoms  of  this  disease,  details  a  typical  case,  and 
observes  that  he  has  seen  over  two  dozen  similar  cases. 
This  observation  is  of  value  as  showing  that  this  malady 
is  not  confined  to  the  Unit(;d  States,  where  it  was  first 
systematically  described,  and  where  it  is  ceitainly  far 


O  PREFACE. 

more  common  than  in  all  the  world  besides,  and  that 
the  symptoms,  behavior,  and  clinical  history  are  the 
same  in  both  countries.  At  the  time  when  my  first 
article  on  this  subject  was  prepared  (1868),  I  used  the 
general  term  neurasthenia  to  cover  all  forms  and  types 
of  nervous  exhaustion,  the  symptoms  coming  from  the 
brain  and  from  the  spinal  cord  being  described  to- 
gether and  indiscriminately.  This  imperfection  Pro- 
fessor Erb  has  repeated,  and,  to  that  extent,  the  value 
of  his  essay  is  impaired,  since,  in  strictness,  the  disease 
neurasthenia  should  appear  both  in  the  volume  on  the 
brain  and  on  the  spinal  cord,  in  the  former  as  cerehras- 
thenia,  or  exhaustion  of  the  brain,  in  the  latter  as 
fnyelasthenia,  or  exhaustion  of  the  spinal  cord.  It  is 
this  latter  form,  or  myelasthenia,  that  Erb  attempts 
to  describe  in  his  volume  under  the  term  neurasthenia 
spinalis;  but  of  necessity  many  of  the  symptoms  con- 
nected with  the  brain  are  included  in  his  description. 

Erb  makes  the  fm-ther  mistake,  but  one  in  which  he 
is  sustained  by  a  large  body  of  writers  on  the  nervous 
system,  of  treating  of  spinal  irritation  as  a  separate 
and  special  disease  instead  of  one  of  the  many  symp- 
toms of  myelasthenia,  or  spinal  exhaustion,  which  it 
really  is;  and  he  further  overlooks  the  existence  of 
cerebral  irritation,  which  is  just  as  real,  though  not 
quite  so  frequent  as  spinal  irritation;  and  he  evidently 
fails  to  recognize  the  fact  that  the  general  irritation 
or  tenderness  of  the  whole  body,  to  which  he  gives  the 
name  hyperaesthesia,  is  in  scientific  analysis  a  condition 
to  be  accounted  for  just  as  much  as  spinal  irritation. 


PREFACE.  9 

Many  important  symptoms  he  does  not  mention,  and 
no  attempt  is  made  to  explain  in  detail  the  diagnosis, 
pathology,  or  rationale  of  the  disease.  It  is  due,  how- 
ever, to  Professor  Erb  to  say  that  he  evidently  suspects 
the  justness  of  his  analysis,  and  in  one  place  clearly 
intimates  that  he  has  doubts  whether  spinal  irritation 
should  be  considered  as  a  distinct  disease;  and  he  con- 
fesses that  it  is  impossible  to  draw  the  hues  between 
spinal  exhaustion  and  spinal  irritation, ' 

So  far  as  I  know,  none  of  the  recent  standard  works 
on  nervous  diseases,  in  any  language,  have  any  chap- 
ter on  neurasthenia,  with  the  exception  of  that  of  Erb, 
above  noted,  and  the  Maladies  du  Systeme  Nerveux 
(Paris,  1879),  by  Dr.  J.  Grasset,  Professor  in  the  Fac- 
ulty of  Medicine,  Montpellier,  France;  and  "Diseases 
of  the  Nervous  System,"  '  by  Rosenthal,  of  Viemia. 

Prof.  Grasset,  however,  unlike  Erb,  makes  no  addi- 
tion to  our  knowledge  of  neurasthenia,  but  simply 
epitomizes  the  facts  and  reasonings  of  my  earlier  es- 
say. In  attempting  to  point  out  the  relation  of  neu- 
rasthenia to  the  special  symptom,  spinal  irritation,  he 
falls  into  the  same  confusion  as  Erb,  without  appar- 
ently suspecting  that  confusion.  Under  the  general 
heading  Spinal  Irritation,  various  phases  of  neuralgia, 
"  cerebro-cardiac  neuropathia  "  and  agoraphobia— fear 

'During  the  past  suiiinier  I  had  the  pleasure  of  meeting  Prof. 
Erl)  in  Heidelberg,  and  <>f  conversing  with  him  in  some  detail  on 
this  subject.  He  stated  tliat  his  exj)erienee  with  ncMir.-isthenia 
had  much  widened  since  the  publication  of  his  oliaptcr  in  the 
CyelopiL'dia.  In  most  respects  1  believe  he  would  accept  the 
criticisms  nnd  suggestions  aliove  ofTered. 

'  This  work  has  been  translated  by  Dr.  Putzel,  of  New  York. 


10  PREFACE. 

of  open  places — are  promiscuously  gathered.  Dr.  Julius 
Althaus,  of  London,  in  the  third  edition  of  his  work 
on  Electricity  (1S73),  has  a  short  chapter  on  "Spinal 
Exhaustion,"  among  the  symptoms  of  which  he  men- 
tions "  nervousness,  impaired  digestion,  and  increased 
elimination  of  urea;  "  and  cites  two  or  three  cases, 
giving  the  results  of  electrical  treatment. 

April  4th,  1878,  I  read  before  the  New  York  Acad- 
emy of  Medicine  a  paper  on  certain  symptoms  of  nerv- 
ous exhaustion,  designed  to  he  supplementary  to  the 
original  paper  on  neurasthenia,  prepared  ten  years  be- 
fore, describing  a  number  of  new  symptoms,  or  those 
but  partially  noticed  heretofore,  and  yet  further  dif- 
ferentiating the  disease.  This  paper,  which  was  based 
on  a  study  of  several  hundred  cases  of  neurasthenia, 
in  its  different  forms  and  phases,  was  subsequently 
published  in  the  Virginia  Medical  Monthly  for  June, 
1878.  Since  that  time,  I  have  continued  the  discussion 
of  the  subject  in  a  number  of  papers,  delivered  before 
the  scientific  societies  of  New  York  and  vicinity,  be- 
fore the  American  Neurological  and  American  Medical 
Associations,  the  New  York  Neurological  Society,  and 
in  a  lecture  before  the  Baltimore  Medical  and  Surgical 
Society.  These  papers  have  been  published  in  the 
various  medical  journals. 

Although  the  first  systematic  indorsement  and  con- 
firmation of  what  had  been  written  on  neurasthenia 
was  obtained  in  Germany,  yet  these  later  writings  have 
both  awakened  interest  and  inspired  activity,  on  the 
part  of  scientific  men  in  this  country,  so  that  already 


PREFACE.  11 

we  have  a  number  of  independent  workers  in  the  same 
field,  among  whom  are  to  be  mentioned  Drs.  Jewell, 
Mitchell,  and  Goodell,  who  have  made,  and  are  still 
making,  thoughtful  and  suggestive  contributions  to 
this  subject. 

In  England,  Mr.  Jonathan  Hutchinson,'  approach- 
ing this  subject  from  the  side  of  ophtlialmology,  has 
by  his  own  observations  confirmed,  though  not  in  a 
systematic  fomi,  some  of  the  facts  and  reasonings  of 
this  treatise. 

It  would,  therefore,  appear  that  the  general  doc- 
trines tauglit  in  this  work  have  already  passed  the  test 
which  every  claim  in  science  must  meet — verification 
by  a  number  of  experts  in  the  branch  t(^  which  it  be- 
longs, and  that  the  time  has  come  to  present  the  sub- 
ject in  a  i)ermaneut  form. 

Although  neurasthenia  had  not  been  systematically 
studied,  yet  that  there  was  a  morbid  c(  )ndition  of  the 
nervous  system,  for  which  the  ordinary  names  and  de- 
scriptions of  the  books  would  not  suffice,  had  been 
suggested  by  various  writers. 

Tims,  Dr.  Flint,  in  the  first  edition  to  liis  work  on 
"  Practice,"  devotes  a  page  to  what  he  calls  "  nervous 
asthenia,"  acknowledging  the  indebtedness  for  that 
term  to  Dr.  Fordyce  Barker.  Dr.  Flint  defines  the 
disease  as  "functional  debility,  induced  by  excessive 
and  luiduly  prolonged  activity  of  the  brain  functions." 
In  spite  of  the  imperfections  of  this  definition,  which 

■See  the  London  Medical  Times  and  Gazette,  June  2l8t  and 
August  23d,  1879. 


12  PREFACE. 

by  no  means  covers  the  facts  of  neurasthenia,  Dr. 
Flint's  few  sentences  on  this  subject  are,  so  far  as  they 
go,  scientific,  suggestive,  and  verifiable,  and  those  who 
are  interested  would  do  well  to  refer  to  them.  He 
states,  for  example,  that  it  occui's  without  anaemia, 
that  it  is  especially  frequent  in  this  country,  and  in 
cities.  In  regard  to  the  special  symptoms,  the  differ- 
ential diagnosis,  or  the  treatment,  he  says  but  little, 
and  concludes  that  "  a  full  consideration  of  nervous 
asthenia  would  require  much  more  space  than  can  be 
accorded  to  it  in  this  work." 

In  his  last  work  on  "  CHnical  Medicine,"  the  author 
repeats  substantially  the  views  of  the  earher  treatise, 
and  adopts  the  term  neurasthenia.  In  the  older  edi- 
tions of  Dunglison's  Medical  Dictionary  the  word  neu- 
rasthenia ai)pears. 

Dr.  Jewell,  of  Chicago,  in  a  series  of  lectures  on  neu- 
rasthenia, now  being  published  in  the  Journal  of  Nerv- 
ous Disease^  refers  to  the  following  terms  that  have 
been  employed  by  writers: — Nervosime  (Bouchut);  etat 
nerveux  (Sandra s  and  Boui'gignon);  nervopathie  pro- 
teiforme  (Cerise);  nervospasmie  (Brachet);  nerven- 
erethismus  (Henle);  neurcemie  (Laycock). 

Benjamin  M.  Richardson,  of  London,  in  his  valuable 
treatise  on  the  "  Diseases  of  Modern  Life,"  also  refers 
to  some  of  the  symptoms  of  neurasthenia,  such  as  ir- 
ritable heart,  and  roaring  in  the  ears,  and  hopelessness; 
taking,  however,  a  more  pessimistic  view  of  such 
symptoms  than  is  consisterit  with  the  facts  as  observed 
in  bhe  majority  of  the  cases. 


PREFACE.  13 

The  propriety  of  publishing  these  researches  is  yet 
further  inculcated  by  the  consideration  of  the  very  im- 
portant progress  that  has  been  made  in  the  treatment 
of  neurasthenia  and  allied  affections,  especially  during 
the  last  decade — cases  which  formerly  were  allowed  to 
suffer  for  years,  and  perhaps  to  develop  special  and 
more  serious  diseases,  are  now,  -uith  our  more  abun- 
dant remedies,  and,  more  than  aU,  with  our  better 
knowledge  of  the  dosage  and  action  of  remedies,  and 
of  the  laws  of  their  combination,  speedily  relieved,  and, 
in  time,  substantially  cm-ed.  In  no  department  of 
therapeutics  has  there  been,  even  in  this  most  active 
age,  so  rapid  and  so  useful  an  advance  as  in  the  man- 
agement of  nervous  exhaustion,  and  the  diseases  that 
result  from  and  are  related  to  it;  and  hence  a  subject 
the  interest  of  which  was  originally  and  mainly  scien- 
tific and  philosophic,  is  now  of  direct  and  practical  and 
personal  concern,  not  only  to  specialists  in  the  diseases 
of  the  nervous  system,  but  to  practitioners,"  and  to 
sufferers  everywhere. 

To  describe  with  thoroughness,  if  not  exhaustively, 
the  symptoms  of  neurasthenia — those  hitherto  assigned 
to  the  other  affections,  or  regarded  as  special  and  dis- 
tinct diseases  themselves;  to  show  their  relations  and 
interdependence  ;  to  distinguisli  them  from  tlie  often 
times  closely  resembhng  symptoms  of  organic  disease 
on  the  one  hand  and  the  symptoms  of  hysteria  and 
hypochondria  on  the  other  hand;  to  unify  and  harmo- 
nize the  complex  developments  and  manifestations  of 
this  malady;  to  indicate  its  pathology  and  rationale, 


14  PREFACE. 

and  trace  out  in  detail  its  prognosis,  sequences,  treat- 
ment, and  hygiene — tliis  is  the  task  I  have  undertaken 
in  the  present  volume. 

In  regard  to  the  nomenclature  adopted  in  this  work, 
this  may,  perhaps  be  admitted,  that  it  is  at  first  annoy- 
ing and  apparently  unnecessary  to  introduce  new  terms 
for  even  frequently  occurring  symptoms.  At  the  be- 
gimiing,  however,  I  may  say  that  the  nomenclature  is 
the  least  important  part  of  the  subject,  and  the  one 
that  is  the  least  insisted  upon.  It  is  the  fact — the  idea 
—the  truth  behind  the  nomenclature  that  demands  our 
attention.  Names,  however,  are  necessary  in  science; 
simply,  if  for  no  other  reason,  for  the  sake  of  economy 
of  time  and  labor  in  expressing  thought;  and  where  a 
subject  is  much  discussed,  this  matter  of  economy  be- 
comes a  matter  of  not  a  little  consideration.  The  ht- 
erature  of  ophthalmology  has  a  very  extensive  nomen- 
clature, which  has  been  made  necessary  by  the 
advances  of  science  in  that  direction,  and  by  which 
communication  and  converse  among  ophthalmolo- 
gists are  made  easier.  New  terms  are  necessary  to  new 
sciences,  although  it  is  not  necessary  that  all  persons 
should  remember  them,  or  try  to  bear  them  in  mind, 
so  long  as  they  understand  the  conditions  which  they 
are  designed  to  express. 

In  devising  new  nomenclature,  certain  hberties  are 
allowed  when  anything  is  thereby  gained  for  brevity 
or  euphony.  Cerebrasthenia,  derived  from  a  Latin 
and  a  Greek  word,  is  preferable  to  encephalasthenia, 
which  would  be  the  term  if  made  up  purely  from 


PREFACE.  16 

Greek.  In  naming  the  morbid  fears,  certain  elisions 
and  abbreviations  are  required  in  order  to  simplify  and 
shorten  the  words,  which  at  best  are  unpleasantly  long. 
There  is  a  proper  repugnance  to  new  terms  which  can 
only  be  met  by  showing  theii'  necessity  or  convenience, 
or  by  making  them  as  brief  and  as  euphonious  as  pos- 
sible. 

It  is  designed  that  this  work  shall  be  exclusively 
practical,  and  for  that  reason  the  causes  of  neurasthe- 
nia here  receive  no  consideration.  In  a  work  on  Amer- 
ican Nervousness  which  is  now  in  preparation  and 
nearly  completed,  and  which  will  be,  in  a  measure, 
supplementary  to  the  present  treatise,  it  is  expected  to 
supi)ly  this  want  and  discuss  both  the  causes  and  the 
consequences  of  the  rise  and  increase  in  motlern  times, 
not  only  of  neurasthenia,  but  of  the  general  nerve- 
sensitiveness  of  which  neui'asthenia,  with  all  its  vast 
array  of  symptoms  and  se^juences,  is  but  a  result  and 
expression.  A  philosophic  and  thorough  analysis  of 
American  nei'vousness  nmst  be  a  contribution  to  soci- 
ology of  which  it  is  a  part,  and  will  require  a  discus- 
sion of  many  questions  of  race,  of  climate,  of  institu- 
tions, and  of  social  customs,  that,  however  interesting 
they  may  Ix)  to  the  general  reader  and  inquirer,  and 
however  imix>rtant  for  a  full  and  strictly  scientific 
apprehension  of  all  sides  of  our  theme,  are  of  less  im- 
mediate concern  to  the  physician  or  the  patient  than  a 
knowledge  of  the  symi)toms,  the  diagnosis,  the  se- 
quences, and  the  treatment  of  neurasthenia.     What 


IC  PREFACE. 

practical  physicians  above  all  things  want  is,  to  have 
a  book  which  should  be  as  a  mirror  held  up  before 
disease  and  reflecting  the  symptoms  and  history,  not 
as  they  logically  might  be  or  ought  to  be,  or  are  sup- 
posed to  be,  but  as  they  are  in  actual  experience.  This 
ideal  the  present  work  aims  to  fulfill. 

Already  the  leading  principles  to  be  taught  in 
the  work  on  American  nervousness  has  been  made 
pubhc  in  various  lectures  and  essays,  and  incident- 
ally and  fragmentarily  also  in  some  of  my  pubhshed 
volumes. 

During  the  past  summer  (1879),  I  brought  the  sub- 
ject before  the  British  Medical  Association,  in  Cork,  in 
a  paper  on  the  Nervous  Diseases  of  America.  During 
this  last  visit  to  Europe,  as  well  as  in  1869,  I  investi- 
gated the  comparative  nervousness  of  Americans  and 
Europeans  with  especial  reference  to  neurasthenia. 
These  topics  have  also  been  discussed  in  a  popular  way 
in  essays  in  the  North  American  Beview,  Atlantic 
Monthly,  and  Appleton'^s  Journal. 

The  facts  and  reasonings  in  these  publications  have 
aroused  considerable  criticism,  notably  in  England,  in 
the  London  Times  and  Spectator  and  other  journals, 
and  to  a  certain  degree  also  in  this  country.  When 
the  work  is  published,  these  criticisms  will  receive 
proper  consideration.  Meanwhile  this  may  be  stated 
in  advance,  that  the  prime  cause  of  modem  nervous- 
ness is  modern  civilization  with  its  accompaniments; 
all  other  accredited  influences,  however  important  and 
interesting,  as  indulgence  of  appetites  and  passions, 


PREFACE.  11 

and  even  climatic  conditions  and  the  nervous  diathe- 
sis, being  only  secondary  or  tertiary. 

I  improve  this  opportunity  to  express  my  obliga 
tions  to  many,  in  my  own  and  in  other  professions, 
patients,  correspondents  and  friends,  who,  m  various 
ways,  have  given  me  important  aid  through  the  long 
period  during  which  these  difficult  researches  have 
been  conducted. 

The  study  of  neurasthenia,  from  its  very  nature,  re- 
quires an  acquaintance,  not  only  with  the  forms  of 
functional  and  structural  diseases  of  the  nervous  sys- 
tem in  general,  but  with  disorders  of  special  organs, 
as  the  eye,  the  ear,  the  throat,  of  the  digestive  and  re- 
productive systems,  as  well  as  of  psychology,  and  the 
phenomena  of  the  involuntary  life  in  health  and  dis 
ease.  In  the  evolution  of  recent  science  and  art,  a 
complete  knowledge  of  these  several  departments  is 
not  possible  to  a  single  human  mind;  specialties  are 
built  upon  other  specialties;  experts  must  lean  on  other 
experts;  we  cannot  walk  a  single  step  alone.  The 
task  of  excluding  organic  disease— the  chief  fact  in 
making  tlie  differential  diagnosis — demands  in  some 
cases  diagnostic  skill  of  the  very  highest  order,  since  it 
is  far  easier  to  see  a  coarse  lesion  when  it  exists  than 
to  make  sure  that  there  is  no  lesion  or  objective  condi- 
tion within  the  range  of  the  aided  or  imaided  senses. 

From  the  beginning  of  my  study  of  the  subject,  es- 
pecially of  late  years,  I  have  been  called  upon  to  diag- 
nosticate and  to  carry  out  the  details  of  treatment  for 
cases  of  neurasthenia  among  veiy  many  of  the  mem- 


1 8  PREFACE. 

bers  of  my  own  profession,  students  of  medicine,  and 
men  of  science;  with  many  of  these  cases  it  has  been 
one  of  the  means  of  cure  to  have  them  study  in  a  scien- 
tific way — through  the  intellect  rather  than  through 
the  emotions — not  only  their  own  experience,  but  the 
general  subject  in  its  various  relations.  Some  of  these 
professional  patients  have  been  men  of  large  practical 
experience,  superior  skill,  and  high  authority  in  their 
respective  departments,  from  whose  general  observa- 
tions and  suggestions  and  special  co-operation  as  ex- 
perts I  have  derived  incalculable  benefit,  which,  as  it 
is  hoped,  this  contribution  to  the  scientific  study  of 
neurasthenia  may  partially  repay. 

G.   M.   B. 


CONTENTS. 


CHAPTER  I. 
Introduction. 


PAOB 

Why  the  Study  of  Neurasthenia  has  been  neglected. — The  Symp- 
toms of  a  Subjective  Character. — Reasoning  vs.  Observa- , 
tion. — Less  Frequent  in  Europe. — More  Medicine  used  in 
America 25-35 

CHAPTER  n. 

Symptoms  of  Nervous  Exhaustion. 

How  to  Study  Cases. — Tenderness  of  the  Scalp. — Cerebral  Irrita- 
tion.—Dilated  Pupils. — Sick  Headache  and  Various  Forms  of 
Head  Pain. — Pain,  Pressure,  and  Heaviness  in  the  Head. — 
Changes  in  the  Expression  of  the  Eye. — Congestion  of  the 
Conjunctiva. — Disturbances  of  the  Nerves  of  Special  Sense. 
— Neurasthenic  Asthenopia. — Muscce.  Volitantes. — Noises  in 
the  Ears. — Atonic  Voice. — Deficient  Mentiil  Control. — Mental 
Irritability. — Hopelessness. — Morbid  Fears. — Astraphobia  or 
Fear  of  Lightning. — Topophobia  or  Fear  of  Places. — Agora- 
phobia or  Fear  of  Open  Places. — Claustrophobia  or  Fear  of 
Closed  Places. — Anthropophobia  or  Fear  of  Society. — Mono- 
phobia or  Fear  of  being  Alone. — Phobophobia  or  Fear  of 
Fears. — Mysophobia  or  Fear  of  Contamination. — Pantapho- 
bia or  Fear  of  Everj'thing. — Symptomatic  Merely. — Morbid 
Fears  Rarely  E.xist  Alone.  Flushing  and  Fidgetiness.  — 
Frequent  Blusbing.  »^  Sleeplessness.  —  Bud  Dreams.  —  In- 
somnia.— Drowsin^s. — Tenderness  of  the  Teeth  and  Gum.s. — 
Nervous  Dyspepsia  (/>y.s;v7)«iV  Asth^nujtte). — Deficient  Thirst 
and  Citpacity  for  Assiniiliiling  Fluids. — Desire  for  Stimulants 
and  Narcotics. — Dryness  of  the  Skin. — Abnormalilies  of  the 
Secretions.  —  Abnormal   Dryness  of  the  Skin,  Joints,  and 


20  CONTENTS. 

/  PAGE 
Mucous  Membranes. — Sweating  Hands  and  Feet  with  Red- 
ness (Palmar  Hyperidrosis). — Salivation.  — Tenderness  of  the 
Spine  (Spinal  Irritation)  and  of  the  whole  Body  (General 
Hypereesthesia). — Coccyodynia. — Peculiarities  of  Pain  in  the 
Back. — Heaviness  of  the  Loin  and  Limbs.— Shooting  Pains 
simulating  those  of  Ataxy. — Podalgia  (Pain  in  the  Feet).— 
Tremulous  and  Variable  Pulse  and  Palpitation  of  the  Heart 
(Irritable  Heart). — Local  Spasms  of  Muscles  (Tremors).  — 
Dysphagia  (Difficulty  of  Swallowing).  —  Convulsive  Move- 
ments, especially'  on  going  to  Sleep. —Cramps. — Special  Idio- 
syncrasies in  regard  to  Food,  Medicine,  and  external  Ii-ri- 
tants. — Sensitiveness  to  Weather. — Sensitiveness  to  Cold  or 
Hot  Water. — Sensitiveness  to  Changes  in  tlie  Weather. — 
Sunstroke  brings  on  many  Symptoms  of  Neurasthenia. — 
Localized  Peripheral  Numbness  and  Hyperiestliesia.  —  A 
Feeling  of  Profovmd  Exhaustion  Unaccompanied  by  Positive 
Pain. — Ticklishness. — Vague  Pains  and  Flj'ing  Neuralgias. 
— General  or  Local  Itching  (Pruritus). — General  and  Local 
Chills  and  Flashes  of  Heat. — Cold  Feetand  Hands. — Nei'vous 
Chills. — Sudden  giving  way  of  General  or  Special  Func- 
tions.— Temporary  Paralysis. — Diseases  of  Men  (Involuntary 
Emissions,  Partial  or  Complete,  Impotence,  Irritability  of 
the  Prostatic  Urethra). — Diseases  of  Women.  —  Oxalates, 
Urates,  Phosphates,  and  Spermatozoain  the  Urine.— Gaping 
and  Yawning. — Appearance  of  Youth. — Rapid  Decay  and 
Irregularities  of  the  Teeth. — Hemi-neurasthenia. — Course 
and  Caprice  of  the  Symptoms.  —  Time  of  Life  at  which 
Neurasthenia  is  most  Frequent.  —  Frequency  of  these 
Diseases. — How  such  Cases  are  usually  diagnosticated. — 
Multitude  of  tlie  Symptoms. — Correlation  of  Nervous  Symp- 
toms         36-117 

CHAPTER  III. 

Nature  and  Diagnosis  of  Nervous  Exhaustion. 

Distinguished  from  Organic  or  Structural  Nervous  Disease. — 1. 
Symptoms  of  Organic  Diseases  fixed  and  stable. — -2.  Neuras- 
thenia has  some  Symptoms  peculiar  to  itself. — 3.  In  Neu- 
rasthenia reflex  Activity  increased. — Reflexes  from  Brain, 
Digestion,  and  Reproductive  Apparatus. — Relation  of  Geni- 
tal Troubles  in  both  Sexes  to  Neurasthenia. — 4.  Neuras- 
thenia most  common  where  Nervous  Diathesis  predominates. 


CONTENTS.  21 

PAGE 

— Characteristics  of  Nervous  Diathesis. — Distinguished  from 
Hypochondriasis  or  Pathophobia. — General  Hopelessness. — 
Groundless  Fear  of  Disease. — Distinguished  from  Cerebral 
and  Spinal  Anaeraias  and  Hypertemias. — Distinguished  from 
Anajniia.  —  Distinguished  from  Hysteria.  —  Distinguished 
from  SN'philis.  —  Distinguished  from  common  Cold  and 
Rheumatism. — Differential  Diagnosis  of  Cerebrasthenia 
(Bi-ain  Exhaustion)  and  Myelasthenia  (Spinal  Exliaustion). — 
Pathology  and  Rationale.  —  Vaso-Motor  Reflexes.  —  Func- 
tional as  distinguished  from  Organic  Disease, — Recapitula- 
tion   ...        118-159 

CHAPTER  IV. 

Prognosis  and  Sequences  of  Nervous  Exhaustion, 

Recent  Progress  made  in  the  Treatment  of  Neurasthenia  and 
Allied  Affections.— Relief  and  Recovery  of  Special  Symp- 
toms.— Prognosis  depending  on  the  hereditary  Character  of 
the  Disease. — Working  Order. — Sequence  of  Neurasthenia. 

—  Insanity  (Melancholia). — Hysteria  and  Hystero-Epilepsy. 

—  General  Neuralgia.  —Inebriety. — Meconism  (Opio-Mania). 
— Disea.se  of  the  Reproductive  Organs.  —  Hay  Fever.  — 
Writer's  Cramp. — Trance. — Paralysis  and  Organic  Diseases 
of  the  Spinal  Cord.  —  Certain  Stages  of  Bright's  Disease 
(Albuminuria) 160-175 

CHAPTER  V. 

Treatment  and  Hygiene  of  Nervous  Exhaustion. 

Each  case  of  Neurasthenia  is  a  study  of  itself.  —  Digestive 
Hygiene. — Milk  Diet.— Rectal  Alimentation.— Rest  Cure  vs. 
Work  Cure.— Rest  and  Isolation. — A  New  Impression  Needed. 
— Seclusion  and  Non-seclusion. — Brain-work  in  Nervous  Dis- 
ea.ses.— The  Psycholf>gy  of  Patients  to  be  .studied. — Enume- 
ration of  Priniipal  Remedies. — Ai-senic. — Cannabis  Indica. — 
UafTeine.- Tea  Tasting.— Caffcinism.— Coca.— Zinc  Combina- 
tions. —  Duboisia.  —  Cimicifugin.  —  Traihng  Arbutus.  — 
Eucalyptus.  —  Hydrastis.  —  Bromides.  — Chloral.  — Chloral 
Asthenopia.— Strychnia.— Opium.— Alcohol. — Mineral  Acids. 
— Cod-Liver  Oil.— Phos|)hafes. — Koumiss.— External  Modes 
of  Tn-alment.  —  Electricity.—  Massage.— Mftalloscopy  and 
Metal  Therapeutics. — Recent  Experiments  in  that  Line.— 


22  CONTENTS. 

PAGE 

Nitrous  Oxide, — Philosophy  of  the  Plan  of  Treatment. — 
Nerve  Alteratives. — Local  Treatment  of  Uterus  and  Prostate 
and  Prostatic  Urethra. — Effects  of  Self -Abuse. — Pei-sistence 
in  Treatment. — Treatment  of  Sequences. — General  and 
Special  Effects  of  this  Combined  Treatment. — Improvement 
in  Sleep. — Mental  and  Physical  Sedation. — Increase  in  Fat 
and  Weight  of  the  Body. — Improvement  in  Appetite  and 
Digestion.  —  Relief  of  Pain  and  Exhaustion.  —  Increased 
Capacity  for  Muscular  and  Cerebral  Toil. — Travelling  as 
Medicine  often  injurious. — Horse-back  Riding,  when  to  be 
avoided. — Clothing  should  be  warm. — Climatology  of  Nerv- 
ous Diseases. — Neurasthenics  benefited  by  a  warm  Climate. — 
Sea  Air  vs.  Mountain  Air. — Nervous  Diseases  of  America  and 
Europe  compared 176-249 


NERVOUS  EXHAUSTIOK. 

(NEURASTHENIA.) 


CHAPTER  I. 

INTRODUCTION. 


WHY    THE    STUDY    OF    NEURASTHENIA    HAS    BEEN    NEG- 
LECTED. 

There  is  a  large  family  of  functional  nervous  dis- 
orders that  are  increasingly  frequent  among  the  in-door 
classes  of  civilized  countries,  and  that  are  especially 
frequent  in  the  northern  and  eastern  parts  of  the 
United  States,  but  of  which  our  standard  works  of 
medicine  and  our  lecture-rooms  give  little  or  no  infor- 
mation. 

The  sufferers  from  these  maladies  are  counted  in 
this  country  by  thousands  and  hundreds  of  thousands; 
in  all  the  Northern  and  Eastern  States  they  are  found 
in  nearly  every  brain-working  household;  and  yet  one 
might  graduate  at  all  of  our  colleges,  read  all  of  our 
most-used  medical  treatises,  and  converse  with  the 
majority  of  our  ablest  practitionei-s,  without  obtaining 
any  just  ideas  in  regard  to  the  nature  or  treatment  of 
these  maladies.  Even  when  these  affections  are 
treated  of  at  all,  it  is,  as  a  rule,  one-sidedly,  i)artially, 
and  erroneously.     Thus,  neurasthenia  is  confounded 


24  NERVOUS  EXHAUSTION. 

with  general  anaemia;  cerebrasthenia  (exhaustion  of  the 
brain)  is  assigned  to  cerebral  anaemia  or  hyperaemia. 
Myelasthenia  (exhaustion  of  the  spinal  cord)  or  spinal 
irritation  is  confounded  with  spondylitis  or  spinal  con- 
gestion, or  is  attributed  to  mere  circulatory  irregulari- 
ties, as  anaemia  or  hyperaemia;  sick  headache  is  re- 
garded as  a  disease  of  the  stomach,  and  treated  with 
antacids  and  purgatives;  physical  hysteria  is  stigma- 
tized as  a  malady  of  the  imagination;  hay  fever  is  sup- 
posed to  be  parasitic  or  infectious;  inebriety  is  mistaken 
for  drunkenness;  while  cerebral  irritation  and  the  dif- 
ferent varieties  of  morbid  fear  are  not  mentioned  at  all. 

Conversing  on  the  subject,  not  long  since,  with  a 
very  intelligent  interne  of  one  of  our  largest  hospitals, 
I  found  that  neither  in  the  medical  school  nor  in  the 
hospital  had  he  received  any  suggestions  relating  to 
any  of  these  functional  diseases  of  the  nervous  system, 
although,  if  he  should  ever  engage  in  private  practice 
among  the  better  classes  of  any  of  our  larger  cities,  he 
will  meet  these  diseases  every  day  and  every  hour, 
and  his  success  will  depend  to  a  considerable  extent 
on  his  skill  in  managing  them. 

These  disorders  are  transmissible  oftentimes,  tak- 
ing the  place  of  each  other.  They  run  in  famihes  more 
demonstrably  than  scrofula,  or  cancer,  or  consumption. 
Indeed,  one  great  cause  of  the  rapid  increase  of  these 
disorders  during  the  first  quarter  of  the  century  has 
been  inheritance.  It  is  not  difficult  to  find  families  in 
which  all  these  diseases  are  represented;  and  there  are 
individuals  who  at  different  times,  or  at  the  same  time, 
suffer  from  all  or  nearly  all  of  them. 

I  have  said  that  in  Europe  these  affections  are  but 
little  known;  but,  in  liability  to  them,  all  the  Euro- 
pean countries  are  not  alike.  They  appear  to  be  least 
common  in  Germany  and  Russia,  Italy  and  Spain; 


INTRODUCTION.  25 

considerably  more  frequent  in  France,  and  more  fre- 
quent still  in  England. 

Although  these  difficulties  are  not  directly  fatal,  and 
so  do  not  appear  in  the  niortahty  tables;  although,  on 
the  conti-ary,  they  may  tend  to  prolong  hfe  and  to 
protect  the  system  against  febrile  and  inflammatory 
diseases,  yet  the  amount  of  suffering  that  tliey  cause 
is  enormous.  Volumes  ai-e  written  on  typhoid  and 
other  fevers;  but  m  this  country  these  neuroses,  al- 
though not  fatal,  cause  more  distress  and  annoyance 
than  all  forms  of  fever  combined,  excepting  perhaps 
those  of  a  malarious  origin.  Fevei*s  kill,  it  is  true, 
while  these  neuroses  do  not;  but  to  many  death  is  by 
no  means  the  most  disagi*eeable  of  the  many^  symp- 
toms of  disease.  A  cyclopaedia  of  medicine,  adapted  to 
the  wants  of  the  practitioner  in  the  northern  and  east- 
ern pai-ts  of  this  country,  should  contain  a  full  volume 
devoted  to  these  diseases;  and  yet,  so  blind  is  our  def- 
erence to  Europe,  so  fearful  are  we  of  making  our  own 
independent,  original  observations  of  the  maladies 
peculiar  to  this  land,  and  so  completely  are  we  tethered 
to  hosi)ital  and  dispensaiy  experience,  that  up  to  the 
present  time  there  is  no  monograph  even  on  these 
diseases,  and  all  attempts  to  study  them,  or  to  diffuse 
a  knowledge  in  regard  to  them,  are  met,  or  have  until 
recently  been  met,  at  every  step  with  inai)preciation 
or  positive  opposition. 

These  diseases  I  bring  into  one  family,  because  they 
have  a  common  pathology,  a  connnon  prognosis,  a 
common  history,  and  a  common  treatment.  They  all 
occur  under  similar  conditions,  and  in  similar  tempera- 
ments. They  are  all  diseases  of  civilization,  and  of 
modem  civilization,  and  mainly  of  tlie  nineteenth  cen- 
tury, and  of  the  United  States.  They  are  to  l)e  dis- 
tinguished  from  certain   other  nervous   diseases,  aa 


26  NERVOUS  EXHAUSTION. 

epilepsy,  and  psychical  or  mental  hysteria,  and  espe- 
cially are  they  to  be  distinguished  from  unquestioned 
structural  or  congestive  diseases,  such  as  locomotor 
ataxy,  progressive  muscular  atrophy,  tetanus,  and 
apoplexy,  all  of  which  diseases  are  probably  thousands 
of  years  old,  are  not  restricted  to  civihzation,  though 
more  frequent  in  civilized  countries,  and  are  as  com- 
mon in  Europe  as  in  America,  if  not  more  so.  These 
organic  or  structm-al  nervous  diseases  also  occur  chiefly 
in  the  strong  or  comparatively  strong;  they  are  not 
diseases  of  nervous  debility,  and  abound  more  among 
the  muscle -working  than  among  the  brain-working 
classes. 

The  centre  and  type  of  this  family  of  functional 
nervous  diseases  is  neurasthenia,  or  nervous  exhaus- 
tion. To  understand  this  disease  is,  therefore,  to  be 
prepared  to  miderstand  all  the  members  of  the  family 
to  which  it  belongs.  For  this  reason  it  is  that  to  the 
study  of  neurasthenia  in  its  varied  forms  and  phases 
this  work  is  devoted. 

Why  is  it  that  this  important  field  of  science  has 
been  so  little  studied?  Why  has  a  disease  which  is 
more  frequent  than  any  other  nervous  disease,  indeed 
may  be  regarded  as  the  king  of  the  neuroses,  succeeded 
so  successfully  in  escaping  the  attention  of  men  of  sci- 
ence?   The  answer  to  this  query  is  somewhat  complex: 

First  of  all,  the  symptoms  of  neurasthenia  are  largely 
of  a  subjective  character,  and  to  one  who  does  not 
suffer  them,  appear  trifling  and  unreal;  many  of  them 
do  not  appeal  directly  to  the  senses  of  the  scientific  ob- 
server: the  physician  can  only  know  of  their  existence 
through  the  statements  of  the  patient,  or  through  his 
conduct.  Uuhke  the  existence  of  surgical  and  acute 
and  inflammatory  diseases,  the  phenomena  of  which 
the  physician  can  see  and  feel,  and  for  the  study  of 


INTRODUCTION.  27 

which  he  is  httle,  if  at  all,  dependent  on  the  patient's 
intelligence  or  honesty,  they  do  not  appeal  directly  to 
the  eye  or  ear  or  touch,  and  are  in  fact  quite  out  of 
the  range  of  aU  modern  appUances  to  suplement  the 
defects  of  the  senses,  as  the  ophthalmoscope  and  laryn- 
goscope, or  even  the  spectroscope.  It  is  the  tendency 
of  the  partially  trained  mind  everywhere  to  reject  or 
doubt  what  cannot  be  confirmed  by  the  eyes  or  ears; 
forgetting  that  the  capacities  of  the  five  senses  of  man 
are  so  meagre  that  tliey  practically  shut  him  out  from 
nature;  forgetting  that  the  gi'eat  natural  forces,  as 
light,  lieat,  electricity,  magnetism,  gi-avity,  are  quite 
beyond  the  reach  of  any  one  of  the  senses,  or  all  of 
them  combined,  scientific  men  have  allowed  them- 
selves to  ignore  and  despise  some  of  tlie  most  remark- 
able, interesting,  and  insti"uctive  phenomena  of  the 
nervous  system  both  in  health  and  disease,  for  the  only 
reasons  that  they  cannot  be  seen  and  heard  and  felt.' 

Then  again,  many  of  these  indefinite  symptoms  of 
nem-asthenia,  considered  alone  and  by  themselves,  are 
so  small,  and  feeble,  and  unimportant  to  those  who  do 

'  Dr.  Jewell,  in  a  recent  lecture,  remarks  as  follows: 
"  In  the  physic^al  science  of  to-day,  there  is  clearly  too  little 
dependence  on,  liecause  there  is  so  much  ijjnorance  of,  the  nature 
>ind  cf)n<liti<)ns()f  inference.  It  is  almost  habitually  placed  at  a 
disadvantjifjfe  as  compared  with  direct  sense,  observation,  and 
physical  demonstration.  Put  this  arises  out  of  wronj;  conceptions 
as  to  its  nature  and  value,  as  well  as  out  of  an  over-estimate  of 
the  dependence  which  we  may  le^;itimatcly  plaee  on  the  'evi- 
dence of  the  senses.'  From  these  rrmarks  you  may  feather,  that  I 
am  aware  of  th(<  real  nature  of  the  description  I  am  about  to 
^ive,  and  also  of  the  objections  which  a  too  realistic  scientific 
spirit  nntrht  raise  afjainst  it  as  to  its  substantial  correctness." 

I  may  here  also  refer  tf)  my  series  of  papers  on  the  Scientific 
Htudy  of  Human  Testimony,  in  the  ropnlnr  Science  Moitthly 
(May,  June,  and  Jidy,  1H78,  and  March  and  April,  1871)),  where 
the  relations  of  inductive  to  deductive  reiu^oning  are  discussed. 


28  NERVOUS  EXHAUSTION. 

not  understand  their  importance,  that  science  passes 
them  by  and  gives  attention  to  matters  incomparably 
less  important  and  valuable. 

Physicians  who  pass  by  these  obscure  phenomena  of 
the  nervous  system,  as  unworthy  of  their  notice,  may 
be  reminded  of  this,  that  modern  science,  in  all  of  its 
branches,  and  particularly  in  biology,  is  constructed  out 
of  sHght,  trifling,  and  unnoticeable  facts  and  phenomena 
of  nature.  Thus,  the  philosophy  of  evolution,  which 
marks  the  highest  achievement  of  the  human  intellect, 
is  built  up  entirely  of  minute  and  apparently  insignifi- 
cant facts,  which  scientific  men  of  past  generations 
would  have  been  ashamed  to  notice.  Neurasthenia  is 
indeed  passing  through,  in  this  generation,  the  same 
history  as  insanity  in  the  past.  The  time  was  when 
the  symptoms  of  insanity  were  believed  to  indicate, 
not  diseases,  but  the  possessing  of  an  evil  spirit;  so 
now,  very  many  of  the  symptoms  of  neurasthenia  have 
been  regarded  by  men  of  science  as  imaginations  of 
the  patients,  proofs  of  hypochondria — a  vague  term 
which,  in  this  generation,  covers  all  symptoms  which 
the  physician  either  doubts  or  misinterprets. 

Although  neurasthenia  is  comparatively  a  modern 
disease,  although  its  symptoms,  as  herein  described, 
are  surpassingly  more  frequent  now  than  in  the  last 
century,  yet  not  a  few  of  these  symptoms  have  existed, 
particularly  in  this  country,  but  more  or  less  in  all  civ- 
ihzed  countries,  for  at  least  a  century  and  longer;  and 
they  have  been  brought  to  the  attention  of  physicians 
in  their  practice,  but  they  have  not  received  their  at- 
tention; the  sufferers  have  simply  been  dismissed  as 
hypochondriacs,  just  as  with  our  ancestors  cases  of 
hysteria  and  insanity  were  shunned  or  dismissed  as 
possessed  of  the  devil. 

A  second  cause  for  the  neglect  of  this  disease  is,  that 


INTRODUCTION.  29 

a  successful  study  of  it  requires  an  exercise  of  the  rea- 
soning as  well  as  of  the  ohserving  powers.  Since  the 
time  of  Lord  Bacon,  and  notably  during  the  last  half 
century,  the  power  of  scientific  observation— seeing, 
hearing,  and  feeling,  and  touching  facts  of  nature — 
has  developed  with  almost  alarming  rapidity,  and  the 
habit  has  even  become  popularized,  so  that  individuals 
of  but  moderate  powei's  are,  in  limited  and  nari'ow 
spheres,  enabled  to  make  original  observations.  It  is 
in  the  powers  of  reasoning  from  observations,  in  co-or- 
dinating the  phenomena  of  nature,  pointing  out  their 
relations,  and  deducing  laws  from  the  observed  phe- 
nomena, that  the  limitation  of  the  human  brain  is 
r,een  at  the  greatest  disadvantage.  To  one  accurate 
and  original  reasoner  tliere  can  be  found  a  thousand 
original  and  accurate  observers — men  who  can  see  and 
hear  and  feel,  without  being  able  to  go  behind  the  phe- 
nomena that  strike  their  senses,  and  explore  througii 
dark  and  devious  pathways  the  domain  of  general  law. 

In  medicine,  especially  in  the  study  of  the  nervous 
system,  deductive  as  well  as  inductive  reasoning  is 
needed.  In  order  to  study  neurasthenia  and  allied  dis- 
eases, such  as  inebriety  or  hysteria  or  hay  fever,  it  is 
needful,  not  only  to  carefully  observe  the  phenomena, 
but  to  observe  large  numbers  of  them  simultaneously, 
and  to  study  them  in  their  relations  to  each  other,  and 
to  other  facts  of  nature,  and  to  do  all  this  with  faculties 
so  well  disciplined  and  trained  that  there  shall  be  no 
over-estimate  of  the  relative  importance  of  special  facts, 
and  no  overlooking  of  any  i)henomena,  however  trifling. 

The  third  cause  of  the  neglect  of  neurasthenia  and 
allied  affections  is,  that  we  have  depended  too  exclus- 
ively, in  the  investigation  of  disease,  on  the  material 
found  in  hospitals,  disponsiiries.  and  other  institutions 
of  charity.     For  reasons  that  will  be  made  clear  in  this 


30  NERVOUS   EXHAUSTION. 

work,  neurastliei]ic  disorders  are  not  found  to  any  very 
great  extent  in  charitable  institutions,  and  are  quite 
rare  among  that  class  for  whom  such  institutions  are 
organized;  those,  therefore,  who  give  the  bulk  of  their 
time  and  thouglit  to  charitable  work  among  the  ab- 
jectly poor  in  institutions,  or  even  out  of  them,  will 
have  but  little  opportunity  to  study  any  of  the  symp- 
toms or  disorders  referred  to  in  this  treatise. 

Young  men  in  their  profession,  who  have  the  leisure 
and  the  power  for  independent  observation,  throw 
themselves  into  charitable  work,  where  very  many  of 
the  symptoms  and  phases  of  the  disease  which  they 
will  be  required  to  combat  when  they  enter  private 
practice  scarcely  ever  appear.  Unmindful  of  the  pro 
found  and  just  remai-k,  attributed  to  a  member  of  the 
English  parUament,  in  a  discussion  of  the  problem 
how  to  relieve  the  poor:  "  Charity  creates  much  of  the 
miseries  it  relieves,  but  does  not  relieve  all  the  misery 
that  it  creates; "  oblivious  also  of  the  historical  fact 
that  very  many  of  the  noblest  and  most  beautiful  dis- 
coveries of  modern  medicine  and  surgery  have  been 
made  outside  of  hospitals,  physicians  are  yet  taught 
and  inspired,  by  every  form  of  influence,  to  give  their 
time  and  force  to  public  institutions,  and  that.  too.  in  a 
period  of  life  when,  if  ever,  original  work  is  to  be  done. 

The  result  of  this  unscientific  philanthropy  is  that 
the  miseries  of  the  poor  have  been  increased  in  mani- 
fold ways,  and  the  miseries  of  the  rich,  the  comfortable, 
and  intelligent  have  been  unstudied  and  unrelieved.' 

'  It  is  proper  to  add  that  this  evil  of  unwise  and  injurious 
charity  is  now  becoming  recognized  by  tbe  profession  of  New 
Yorlc  and  other  great  cities,  and  that  attempts  have  been  made, 
though  not  very  successfully,  during  the  past  year,  to  remedy  the 
difficulty.  The  strong  and  truthful  paper  of  Dr.  Sturgis  on  this 
subject  is  especially  worthy  of  note. 


INTRODUCTION.  31 

When  our  young  men  in  science  learn,  as  they  are 
now  beginning  to  learn,  that  much  of  charity  is  really 
but  another  term  for  cruelty;  and  that  it  is  possible  to 
make  original  contributions  to  science  from  the  ma- 
terial obtained  in  private  practice;  that  Fifth  Avenue 
is  in  some  features  a  v^ery  much  better  field  for  patho- 
logical study  than  Five  Points;  then  we  may  expect 
and  hope  that  neurasthenia,  the  most  common,  one  of 
the  most  distressing,  and  scientifically  one  of  the  most 
instructive  and  interesting  of  the  nervous  diseases  of 
modern  times,  will  receive  a  trifle  of  the  reflection  and 
observation  that  are  now  bestowed  on  such  minor 
maladies  as  ataxia  and  muscular  atrophy,  with  the  dis- 
cussions of  which  our  text-books  and  literature  are  op- 
pressively burdened. 

A  fourth  cause  of  the  neglect  of  neurasthenia  and 
allied  diseases  is,  that  we,  in  this  comitry,  where  the 
disease  most  abounds,  have  depended  so  exclusively  on 
European  precedence  and  experience.  Until  quite 
lately,  the  majority  of  our  text-books  were  of  European 
origin;  not  only  for  original  studies,  but  for  comi)ila- 
tion  and  text-books,  we  have  looked  to  England  and 
France  and  Germany.  In  Europe  these  fmictional 
nervous  diseases,  although  they  exist,  yet  are  so  rare 
that  even  specialists  in  diseases  of  the  nervous  system 
do  not  see  them  constantly,  and  when  they  see  them, 
do  not,  with  very  few  exceptions,  recognize  or  treat 
them.' 

Neurasthenia  is  an  American  disease  in  this,  that  it 
is  very  much  more  common  here  than  in  any  other 
part  of  the  civilized  world,  and  here  it  fu^t  received  its 
name  and  description;  it  could  not  be  expected  that 

' Prof.  Erb,  of  Hf idtllHTpr,  tells  iii»>  that  in  (Tenuany,  as  in  this 
oountry,  it  ha»  been  tlie  fu^hiuu  to  diagnose  ueurastheuia  as 
hypochondria. 


32  NERVOUS  EXHAUSTION. 

European  authorities  would  be  the  pioneers  either  in  the 
study  of  its  nature  or  treatment.  Neurasthenia,  indeed, 
hke  the  decay  of  the  teeth,  which  in  some  cases  is  really 
one  of  the  symptoms  of  the  neurasthenic  tendency, 
was  first  made  of  special  consequence  in  this  country. 
Within  recent  years,  various  statistics  have  been  pub- 
lished on  the  subject  of  the  disproportion  of  doctors  of 
medicine  to  population.  It  is  said,  and  truthfully,  that 
in  this  country  there  are  more  physicians  in  proportion 
to  the  people  than  in  any  other  country.  These  statis- 
tics have  been  brought  up  mainly  by  those  who  seek  in 
some  way  to  limit  the  graduation  of  doctors;  but  the 
figures  have  been  used  in  such  a  way  as  to  give  an  im- 
pression not  entirely  correct.  The  fallacy  in  them  is 
this,  that  Americans  need  more  doctoring  than  any 
other  people;  they  have  more  illnesses  of  various  kinds 
—major  and  minor— than  any  of  the  European  nations. 
A  hundred  well-to-do  families  in  our  large  cities  would 
send  for  a  doctor  to  treat  them  very  many  more  times 
than  a  hundred  equally  conditioned  famihes  in  Eng- 
land, France,  or  Germany.  This  fact,  taken  in  con- 
nection with  the  fact  that  our  population  extends  over 
a  wide  teritory,  makes  it  possible  to  support  a  larger 
number  of  physicians  than  in  any  other  country  of 
equal  population.  What  is  true  of  doctors  is  equally 
true  of  drug  stores;  the  meagreness  of  the  apothecary 
shops  strikes  one  immediately  on  visiting  Europe. 
The  A^mericans  take  very  much  more  medicine,  both 
prescribed  and  unprescribed,  than  Europeans;  they 
take  a  larger  variety,  they  take  finer  qualities;  hence 
it  is  that  very  many  of  our  drug  stores  are  palaces ' 

'The  past  summer  (1879)  I  had  much  difficulty  in  procuring 
from  the  best  drug  stores  of  London,  Paris,  and  Brussels  such 
remedies  as  bromide  of  sodium  and  citrate  of  caffeine,  in  quanti- 
ties sufficient  for  the  treatment  of  the  sea-sick  on  my  return 
voyage. 


INTRODUCTION.  33 

containing  an  immense  quantity  of  medicinal  prepara- 
tions, including  not  only  all  that  are  used  in  Europe, 
but  many  that  are  peculiar  to  this  country,  or  at  least 
but  very  Uttle  known  abroad. 

Neurasthenic  patients  and  neurasthenic  famihes, 
even  when  they  have  no  febrile  and  inflammatory  dis- 
ease, are  subject  to  numberless  symptoms  of  disease 
that  invite,  if  they  do  not  absolutely  require,  medical 
advice  and  medical  treatment.  They  keep  our  physi- 
cians constantly  on  the  alert  to  advise  and  suggest  for 
them  new  remedies  and  modes  of  treatment;  hence 
it  is  that  the  treatment  of  disease  in  this  country 
among  the  leading  physicians  is  more  satisfactory  in 
all  respects  than  in  Europe;  Germany,  that  leads  the 
world  in  science,  being  far  behind  in  the  art  of  thera- 
peutics. 


CHAPTER   II. 

SYMPTOMS   OF   NERVOUS  EXHAUSTION. 

The  symptoms  of  neurasthenia  have  never  yet  been 
fuUy  described. 

In  my  first  paper  on  this  subject,  I  indicated  only  a 
minority  of  the  signs  and  evidences  of  this  many- sided 
and  fluctuating  disorder,  although  the  general  philoso- 
phy of  this  morbid  condition  was  precisely  the  same  as 
that  advocated  in  this  volume. 

The  present  chapter,  in  the  form  here  given,  is  an 
evolution  from  a  few  independent  observations,  to 
which  others  have  been  added  little  by  little,  by  suc- 
cessive and  slowly  appearing  increments. 

From  medical  literature,  for  reasons  already  given, 
only  inconsiderable  assistance  could  be  obtained.  In 
order  to  learn  the  nature  and  symptoms  of  this  mal- 
ady, it  was  necessary  to  closely  study  the  cases  by 
themselves,  taking  notes  of  their  histories  and  progress, 
with  no  other  guidance  than  that  obtained  from  my 
own  preceding  observations  of  similar  cases,  and  oc- 
casional hints  from  physicians  with  whom  I  saw  the 
patients,  or  by  whom  they  were  referred  to  me. 

Some  of  the  symptoms  that  I  shall  here  describe  are 
somewhat  famihar  to  aU  medical  men  everywhere; 
though  usually  under  different  headings,  and  without 
any  definite  relation  to  any  definite  morbid  state ; 
others  are  familiar  only  to  those  who  give  their  time 
chiefly  to  the  nervous  system,  and  others  still  are  here 
described  for  the  first  time. 

Some  of  the  symptoms  herein  detailed,  when  they  are 


SYMPTOMS  OP  NERVOUS  EXHAUSTION.  35 

mentioned  at  all  in  works  on  diseases  of  the  nervous 
system,  have  been  and  are  now  reJteiTed  to  under  such 
headings  as  cerebral  anaemia  or  hyperaemia,  or  general 
anaemia,  or  hysteria,  or  hypochondriasis,  or  oxaluria; 
and  some  of  them,  as  will  be  seen,  are  mentioned  in 
connection  ^ith  structural  lesions,  as  ataxy  and  mus- 
cular atrophy,  and  by  many  are  regarded  as  essential 
parts  of  the  clinical  image  of  these  grave  disordei^s. 
Neurasthenia  attacks  or  is  Hable  to  attack  all  functions 
and  organs.  Hence,  a  description  of  the  disorder,  to  be 
complete,  must  include  the  varied  modifications  that 
many  parts  and  functions  experience  under  the  influ- 
ence of  a  neurasthenic  invasion. 

Hovj  to  Study  Cases. — One  reason  why  neurasthe- 
nia has  been  so  long  neglected  is,  that  the  symptoms 
are,  in  some  instances,  so  subtle,  illusory,  and  difficult 
of  analysis  and  classification.  One  who  has  never  seen 
and  carefully  examined  a  large  number  of  cases  of  this 
disease  would  not  believe  it  possible  that  it  could 
manifest  itself  in  so  many  different  ways.  The  usual 
custom  of  giving  an  opinion  in  cases  of  this  sort,  after 
slight,  partial,  incomplete  examinations,  including 
very  short  conversations  with  the  patient,  or  perhaps 
only  with  friends  of  the  i)atient,  never  leads  to  good 
results.  Both  physicians  and  patients  have  for  years, 
if  not  for  ages,  encouraged  the  custom  of  calling  upon 
the  physician  for  the  symptoms  here  described,  and 
expecting  that  a  brief  conversation,  more  or  less,  will 
suffice  to  establish  a  diagnosis  and  lay  out  a  course  of 
treatment.  Now,  as  ai-ule,  it  requires  more  than  a  few 
minutes'  conversation  to  make  clear  the  diagnosis  in 
tliis  disorder,  and  the  euro  is  not  usually  to  be  wrought 
by  a  single  carelessly  prepared  prescription. 

Tliese  symptoms  of  neurastlienia,  cerel)rasthenia, 
and  myelasthenia,  as  has  been  stated  in  the  introduc- 


36  NERVOUS  EXHAUSTION. 

tion,  do  not  appeal,  many  of  them,  directly  to  the 
senses;  we  only  learn  of  their  existence,  in  many  cases, 
by  close  cross-examination  of  the  patient  and  the  pa- 
tient's friends,  or  of  the  physician  who  brings  the  pa- 
tient for  consultation.  Before  entering  upon  a  study 
of  this  class  of  cases,  it  is  well  to  examine  the  princi- 
ples of  the  evidence  derived  from  human  testimony,  so 
as  to  know  what  to  accept  and  what  to  reject;  else  we 
may  be  misled  at  every  step. 

Many  of  these  cases,  in  a  first  interview  with  me, 
give  a  history  of  their  life,  and  their  disease  and  symp- 
toms, in  all  sincerity  and  Avith  very  great  care,  which 
on  a  further  examination  and  at  subsequent  interviews 
I  have  found  to  be  not  only  untrue  in  many  important 
respects,  but  even  quite  the  reverse  of  the  truth ;  while 
symptoms  and  facts  which,  when  known,  determine 
the  diagnosis,  are  kept  back,  or  altered,  or  denied^ not 
usually  so  much  through  intentional  deception  as 
through  f  orgetf  ulness,  or  perhaps  through  a  misunder- 
standing or  misapprehension  of  the  purjjort  or  impor- 
tance of  the  questions  that  were  asked.  I  have  had 
patients  of  high  intelligence,  thorough  education,  and 
good  mental  discipline,  give  me  a  history,  at  the  first 
interview,  of  the  nervous  diseases  in  their  family  which 
has  misled  me,  and  was  only  corrected  perhaps  after  I 
had  seen  them  a  number  of  times.  In  very  many 
cases  it  has  happened  to  me  that  patients  denied  that 
there  was  nervous  disease  in  their  family  or  even 
among  their  distant  connections,  when  on  subsequent 
examinations  I  have  found  there  had  been  epilepsy, 
neuralgia,  hysteria,  sick  headache,  hay  fever,  and  even 
insanity — or  perhaps  all  these  disorders  rumiing 
through  many  generations.  I  have  had  patients  come 
to  me  with  some  one  symptom — say  sick  headache  or 
neuralgia  or  spinal  irritation — who  have  said  to  me  in 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  37 

reply  to  questions,  and  also  voluntarily,  that  in  all  their 
Uves  they  had  never  suffered  from  any  other  symptom 
of  nervous  diseases  than  that  one;  whereas,  on  further 
examination,  I  have  found  that  the  symptoms  which 
sent  them  to  me  was  only  one  of  a  large  family  or  army 
of  troubles  which  had  annoyed  and  followed  them  for 
years.  To  study  these  cases  successfully,  one  must, 
therefore,  give  much  time  and  thought,  and  either  by 
correspondence  or  personal  interview — preferably,  of 
course,  the  latter — obtain  accurate,  and  as  far  as  possi- 
ble complete,  knowledge  of  all  their  symptoms,  includ- 
ing those  even  the  most  seemingly  trifling  and  unim- 
portant, and  even  fanciful. 

The  effect  of  this  scientific  analysis  of  cases  is  not  to 
make  our  patients  hypochondriacal,  but  to  remove 
their  hypochondria.  The  worst  enemy  of  the  emotions 
is  the  intellect,  and  by  getting  a  patient  intellectually 
interested  in  his  own  case,  by  assisting  him  to  face  the 
enemy,  we  can  put  him  in  a  position  to  understand 
that  his  troubles,  serious  as  they  may  be,  are  not  so 
serious  as  he  had  feared. 

It  is  very  often  necessary  to  ascertain  the  condition 
of  all  or  nearly  all  of  the  important  organs  and  func- 
tions. The  eyes,  the  ears,  the  spinal  cord,  the  diges- 
tion, the  reproductive  organs  should  be  inquired  into 
with  more  or  less  detail.  Many  of  these  cases,  when 
we  see  them  for  the  first  time,  have  passed  through 
certain  stages  of  the  disease,  symptoms  wliicli  tliey 
have  forgotten,  and  the  existence  of  which  they  will 
deny,  for  the  sole  reason  that  they  have  forgotten  them, 
and  not  from  any  desire  to  deceive  us. 

Experiences  of  this  kind  are  most  suggestive  illus- 
trations of  the  limitations  of  the  human  memory — a 
subject  which  I  have  discussed  elsewhere.  It  is  one 
of  the  blessed  orderings  of  nature  that  we  can  and  do 


38  NERVOUS  EXHAUSTION. 

lose  remembrance  of  our  miseries — the  physical  pains 
and  sufferings  of  the  past,  instead  of  accumulating 
like  pent-up  waters,  pass  silently  away  into  the  caverns 
of  forgetfulness;  like  certain  streams,  of  which  it  is 
said  that  they  sink  into  the  earth,  remain  quite  out 
of  sight,  and  appear  to  view  only  at  long  intervals. 
It  is  this  forgetfulness  of  physical  pain  and  discomfort 
that  makes  existence  possible  or  endurable.  All  per- 
sons would  want  to  die,  all  persons  would  die,  if  they 
were  obliged  to  remember  and  keep  before  the  mind 
at  all  times,  or  were  even  able  to  recollect  all  the 
physical  sufferings  of  the  past;  but  this  very  forgetful- 
ness of  symptoms  and  sickness  makes  it  harder  for  the 
physician  to  diagnosticate  functional  nervous  diseases. 

Some  cases  of  this  kind  illustrate  this  principle  in 
a  most  remarkable  way. 

I  lately  cured  a  very  remarkable  case  of  neurasthenia 
complicated  with  astigmatism,  where  the  patient  took 
pains  to  write  out  and  give  me  in  detail  a  history  of 
the  symptoms.  I  treated  him  for  a  long  time,  saw 
him  many  times,  conversed  with  him  freely  about  his 
case,  in  which  I  felt  a  special  interest,  as  he  well  knew, 
both  on  account  of  its  peculiar  history  and  the  special 
results  of  the  treatment,  and  towards  the  close  of  the 
treatment  presented  him  before  the  American  Neuro- 
logical Association;  but  even  after  all  that  I  learned 
from  him  of  symptoms  that  he  had  suffered,  various 
forms  of  morbid  fear  that  he  had  experienced  and  re- 
covered from,  but  which  he  had  never  Ijefoi'e,  during 
all  the  treatment,  mentioned  to  me. 

Symptoms  of  Nervous  Exhaustion. — Exact  logical 
order  is  impossible,  but  for  convenience  sake  and  for 
ease  of  reference,  I  begin  with  the  head  and  l^rain  and 
go  downwards. 

Tenderness  of  the  Scalp  (Cerebral  Irritation). — This 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  39 

is  a  phenomenon  which  is  to  the  head  what  spinal  irri- 
tation is  to  the  spine.  As  in  spinal  irritation,  the 
whole  spine  may  be  tender  all  the  way  from  the  first 
cervical  vertebra  to  the  coccyx;  or  the  tenderness  may 
be  confined  to  the  middle  dorsal  and  middle  lumbar 
vertebra?;  so,  in  cerebral  irritation  there  may  be  ten- 
derness over  the  entire  scalp,  or  it  may  be  confined  to 
the  vertex,  or  to  certain  points  in  the  forehead.  Some- 
times the  scalp  is  so  tender  that  biTishing  the  hair 
causes  pain;  even  touching  the  tips  of  the  hair  is  dis- 
agreeable. At  the  vertex,  the  tenderness  is  sometimes 
accompanied  by  a  feeling  of  heat  and  burning,  that 
may  be  somewhat  relieved  by  fu^m  pressure.  This 
cerebral  tenderness,  hke  spinal  tenderness,  is  superficial 
and  peripheral,  not  deep-seated  nor  central,  as  some 
have  supposed.  It  is,  in  many  if  not  in  all  cases,  ten- 
derness of  the  ramifications  of  the  occipital  and  other 
nerves  that  supply  the  scalp,  just  as  spinal  irritation 
is  tendemess  of  the  superficial  nerves  of  the  bones  of 
the  spinal  column. 

A  frequent  spot  of  tenderness  is  found  over  the  eye- 
brow and  in  the  left  temple.  This  is  found  in  sick 
headache,  and  in  connection  with  it  there  may  be 
tendemess  of  the  nape  of  the  neck.  A  sudden  jar,  as 
when  one  slips  in  going  down-staire,  may,  in  these 
cases  of  cerebral  irritation,  cause  temporary  pain,  as 
thougli  the  head  itself  had  been  struck.  Emotional 
disturbance  of  any  sort  may  bring  on  an  attack  of  this 
symptom,  as  also  may  confinement  in  heated  rooms, 
or  in  bad  air,  or  over  mental  labor.  These  symptoms, 
indeed,  are  not  constant,  but  come  and  go  according 
to  the  exciting  causes.  Sometimes  they  last  but  for 
an  hour  or  two,  or  for  a  day  or  part  of  a  day.  The 
same  is  true  of  all  analogous  states,  as  spinal  tender- 
ness and  general  hyperiesthesia. 


40  NERVOUS   EXHAUSTION. 

Dilated  Pupils. — Dilatation  of  the  pupils  is  so  often 
seen  in  neurasthenia  that  it  may  be  considered  as  an 
important  fact  to  be  noted  in  the  study  of  a  case. 

Abnormal  activity  of  the  pupil — sudden  and  frequent 
alternations  between  contraction  and  dilatation — is  a 
sign  of  neurasthenia,  or,  at  least,  of  nervous  irritabil- 
ity, of  perhaps  more  importance  than  mere  dilatation, 
just  as  in  organic  diseases  of  the  cord,  sluggishness  of 
the  pupils,  slowness  to  contract  or  dilate,  has  been 
recently  suggested  as  a  better  diagnostic  sign  than 
mere  contraction  of  one  or  both  pupils. 

Temporary  inequality  of  the  pupils — one  being  at 
times  more  dilated  than  the  other — I  have  seen  in 
neurasthenia.  Permanent  inequality  of  the  pupils  is  a 
sign  of  organic  disease;  but  this  neurasthenic  inequal- 
ity is  inconstant,  varying  with  the  general  condition. 

Sick  Headache  and  Various  Forms  of  Head  Pains. 
— Sick  headache  is  both  a  symptom  and  a  safety-valve. 
If  one  must  be  nervous,  an  occasional  attack  of  sick 
headache,  if  it  be  not  too  severe,  is  an  excellent  way 
for  this  nervousness  to  manifest  itself,  and,  no  doubt, 
saves  other  and  worse  affections.  When  sick  head- 
aches suddenly  and  permanently  leave  us,  there  may 
be  reason  to  beware,  though  not  probably  in  all  cases. 
Some  years  ago,  I  had  under  my  care,  for  a  short  time, 
a  case  of  shaking  palsy  that  had  followed  a  sudden  and 
apparently  causeless  cessation  of  sick  headache.  When 
sick  headache  leaves  us  as  a  result  of  improvement  of 
the  nervous  system  through  treatment  or  hygiene,  it 
is  so  far  forth  a  good  sign. 

Like  most  of  the  symptoms  of  nervous  exhaustion  I 
am  here  describing,  sick  headache  is  experienced 
mostly  between  the  ages  of  fifty  and  fifteen.  Earely, 
or  never,  do  young  children  have  it,  and  it  usually 
stops  before  old  age.    It  is  a  symptom  that  belongs  to 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  41 

the  perturbable  and  active  years,  and  may  quickly  show 
itself  when,  from  any  cause,  the  nervous  system  is  de- 
pleted of  its  force. 

Pain,  Pressure  and  Heaviness  in  the  back  of  the 
head  and  over  the  vertex  and  through  the  whole  head, 
very  commonly  attend  the  neurasthenic  state,  especially 
when  the  brain  is  congested;  but  many  also  appear 
where  there  is  no  evidence  of  an  excess  of  blood  on  the 
brain.  Lightness  of  the  head  is  also  a  common  com- 
plaint; also  a  symptom  usually  defined  as  "  I  cannot 
teUhowIfeel." 

Changes  in  the  Expression  of  the  Eye. — The  mere 
expression  of  the  eye  is  modified  by  disease  in  a  way 
that  it  is  hard  to  analyze  or  describe.  In  chronic 
nervous  exhaustion  from  any  cause  or  combination  of 
causes,  this  expression  of  debility  may  become  chronic 
— a  permanent  state  that  is  revealed  at  once  on  meet- 
ing and  addressing  the  sufferer.  In  the  exhaustion 
that  precedes  death,  the  eye,  as  has  been  observed, 
sometimes  protrudes  far  more  than  is  natural.  It  is 
believed  that  this  i)henomenon  takes  place  through  the 
sympathetic. 

A  lady  whom  I  once  treated  for  numerous  neiwe 
difficulties,  and  wlio  entirely  recovered,  told  me  that 
as  she  got  better  the  whites  of  her  eyes  were  of  a 
clearer  blue,  and  consequently,  to  her  delight,  more 
attractive.  This  fact  was  observed  by  several  of  her 
friends  as  well  as  myself.  It  is  a  matter  of  disi)ute 
with  Darwin  and  others,  who  have  written  on  the  ex- 
pression of  the  emotions,  whether  the  eyeljalls  can  or 
cannot  express  feeUng  indei)endent  of  the  lids.  The 
affirmative  view  is  verifiable. 

Congestion  of  the  Conjunctiva. — One  of  the  many 
ways  in  which  neurastlionia  affects  the  eyes  is,  by 
congestion  of  the  conjunctiva.     This  passive  conges- 


42  NERVOUS  EXHAUSTION. 

tion  comes  and  goes,  like  all  the  other  symptoms, 
being  very  bad  in  the  morning,  and  almost  disappear- 
ing by  night,  or  perhaps  in  the  course  of  an  hour  or 
two,  I  have  now  under  care  a  i^atient  in  ^vhom  this 
symptom  is  a  very  striking  one.  When  at  its  worst, 
he  looks  as  though  he  had  been  drinking  heavily,  or 
as  though  he  were  suffering  from  a  v^ery  severe  cold 
in  his  eyes.  The  condition,  or  rather  the  tendency  to 
the  condition,  is  a  chronic  one,  and  increases  and  dis- 
appears in  proportion  to  the  improvement  in  his 
nervous  system. 

Disturbances  of  the  Nerves  of  Special  Sense. — A 
malady  of  the  eye  is  what  I  may  call  neurasthenic 
asthenopia,  or  the  irritable  eye,  from  nervous  exhaus- 
tion, not  depending  solely  on  any  muscular  or  accom- 
modative trouble,  but  mainly  symptomatic,  revealing 
nothing  very  satisfactory  to  the  ophthalmoscope  or 
other  tests  of  modeni  ophthalmology,  but  none  the  less 
painful,  distressing,  and  sometimes  exceedingly  obsti- 
nate. This  disease  of  the  eye,  symptomatic  of  nervous 
exhaustion,  I  observed  a  number  of  years  ago,  but 
could  find  no  formal  recognition  of  it  in  the  standard 
text-books  of  ophthalmology.  Dr.  Mathewson,  in 
conversation  on  the  subject,  tells  me  that  this  third 
form  of  asthenopia  is  now,  however,  under  various 
names,  coming  into  recognition  in  the  journals  and 
societies  devoted  to  diseases  of  the  eye.  For  a  time  it 
was  supposed  that  Donders  had  solved  all  the  problems 
of  asthenopia;  but  it  is  now  known  that  there  are 
many  cases  that  cannot  be  cured  by  glasses.  These 
cases  are  common  in  this  country,  and.  Dr.  Roosa  tells 
me,  were  first  observed  by  our  ophthalmologists. 

An  attack  of  this  neurasthenic  asthenopia — which  is 
oftentimes  so  severe  that  reading  or  writing  or  sewing 
are  accomplished  only  with  great  pain,  and  the  eyes  are 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  43 

painful  and  tender  on  pressure  even  when  not  used— 
may  last  half  an  hour,  or  three  houi-s,  or  three  months; 
and,  hke  analogous  states  in  other  parts  of  the  body, 
with  which  it  is  often  accompanied,  may  come  and  go 
very  suddenly.  Sometimes  there  is  dimness  of  vision. 
In  looking  at  the  eye  when  in  one  of  these  attacks,  we 
may  observe  a  passively  venous  congested  state  of  the 
conjunctiva.  This  congestion  is  a  result— not  the  cause 
— the  effect  of  the  nervous  irritation,  and  comes  and 
goes  under  exciting  causes.  Such,  without  question, 
is  the  jjathology  of  cerebral  irritation,  of  spinal  irrita- 
tion, of  irritation  of  the  mammae,  the  ovaries  and  testes, 
and  of  sick  headaclie  and  many  other  forms  of  nem-al- 
gia.  The  notion  which  has  been  advocated — that  this 
neurasthenic  asthenopia,  or  irritable  eye,  is  pecuhar  to 
women,  and  therefore  to  be  called  uterine  asthenopia, 
is  but  an  adumbration  of  the  truth ;  for  the  malady, 
though  most  common  in  women,  like  all  this  family  of 
symptoms,  is  found  in  both  sexes;  the  very  worst  cases 
I  have  ever  seen  have  been  in  males.  Several  of  my 
cases  have  been  examined  by  our  best  experts  in  oph- 
thalmology. Jonathan  Hutchinson,  of  London,  in  a 
recently  published  lecture,  has  confirmed  the  position 
here  taken.  In  these  cases  there  may  be  insufficiency 
of  the  internal  recti  or  hypermetropia,  etc.,  but  not 
enougli  to  account  for  tlie  symptoms,  and  glasses  do 
not  cure  them.  This  form  of  eye  weakness  is  quite 
susceptible  to  the  influence  of  physical  contagion.  A 
number  of  years  ago  it  spread  through  many  of  the 
colleges  and  seminaries  of  the  country — in  some  in- 
stances com  J  jelling  young  men  to  abandon  their  plans 
of  a  liberal  education. 

Mnscw  Volitantes,  or  floating  specks  before  the  eyes, 
often  annoy  even  the  slightly  nervously  exhausted;  in 
these  cases,  the  ophtbalmoscope  is  only  of  negative  as- 


44  NERVOUS  EXHAUSTION. 

sistance.  Under  exciting  causes,  the  specks  suddenly 
appear  and  disapj)ear.  The  UabiUty  to  them  may  be 
a  habit  of  one's  life.  They  come  and  go  Hke  other 
nervous  systems. 

Noises  in  the  Ears  in  the  shape  of  sudden  explosions 
or  pulsations,  to  say  nothing  of  other  varieties  of  tin- 
nitus aurium,  are  quite  common  in  cerebral  exhaustion, 
especially  when  attended  with  congestion.  Tliese  ex- 
plosions may  come  on  without  any  warning,  while  one 
is  sitting  quite  still,  and  there  is  no  apparent  exciting 
cause.  These  symptoms  may  occur  even  when  there 
is  no  perceptible  disease  of  the  auditory  apparatus,  and 
may  disappear  as  suddenly  as  they  appear.  A  feehng 
of  fullness  and  opi^ression  in  the  head  sometimes  at- 
tends these  symptoms.  Subjective  odors  of  various 
kinds— as  of  ozone  or  phosphorus;  also  abnormal  sub- 
jective tastes — bitter  or  sour,  with  other  fleeting  symp- 
toms of  cerebral  exhaustion,  are  observed. 

Sometimes  there  is  a  pumping  sound  in  one  or  both 
ears,  synchronous  with  the  movements  of  the  heart, 
worse  usually  dming  or  after  exertion,  as  going  up- 
stairs; and  it  may  be  very  annoying  when  one  is  very 
still,  as  when  lying  down  in  bed  in  the  night;  it  is  apt 
to  be  worse  when  stooping,  or  when  worried  or  annoyed 
or  flurried  by  any  mental  emotion.  If  this  symptom 
were  a  constant  one,  and  were  always  associated  with 
demonstrable  disease  of  the  drmn  or  middle  ear,  it 
might  not  perhaps  be  so  gTeat  a  mystery;  but  appear- 
ing as  it  sometimes  does  in  those  whose  hearing  is 
clearly  perfect  or  nearly  so,  and  coming  and  going  al- 
ternate with  other  symptoms  of  neurasthenia,  without 
oftentimes  any  exciting  cause  being  traced,  it  is  prob- 
ably due  to  the  hyperaesthesia  of  the  auditory  nerve 
and  analogous  to  that  of  the  retina;  and,  Uke  the 
retinal  hyperaesthesia,  it  is  inconstant,  variable,  and 


SYMPTOMS   OF   NERVOUS   EXHAUSTION.  45 

capricious.  My  friend  Dr.  Schell,  of  Philadelphia,  tells 
me  that  he  has  seen  a  number  of  cases  where  there 
were  attacks  of  pain  and  aching  in  the  ear,  analogous 
to  the  pain  and  aching  of  the  neurasthenic  eye;  but  to 
account  for  which  no  objective  appearances  can  be 
found. 

Atonic  Voice. — When  neurasthenia  lays  its  hands 
on  a  man,  it  is  Hable  to  leave  its  impress  on  every  or- 
gan and  function  of  the  body;  from  the  crown  to  the 
toe  there  is  not  a  fibre  that  is  safe  from  attack.  If 
some  parts  escape  in  one  individual,  they  suffer  in 
others.  If  at  one  stage  of  the  malady  certain  regions 
are  unaffected,  it  may  be  only  that  they  may  be  at- 
tacked ^vith  all  the  gi'eater  violence  at  another  stage. 
Thus  the  hair,  the  scalp,  the  eyes,  the  ears,  the  nasal 
and  respiratoiy  passages,  the  brain,  in  whole  or  in 
part,  the  cranial  nerves,  the  heart,  the  spinal  cord  in 
any  portion,  the  sensory  and  motor  nerves,  the  stom- 
ach and  bowels,  the  reproductive  system,  the  skin, 
the  nails,  the  secretions,  the  excretions,  the  absorbents 
— all  are  objects  of  assault. 

It  is  not  strange,  therefore,  that  there  should  be  a 
neurasthenic  voice,  just  as  there  is  a  neurasthenic  eye, 
a  neurasthenic  stomach.  Tlie  chief  peculiarity  of  the 
neurasthenic  voice  is  softness,  faintness,  want  of  cour- 
age and  clearness  of  tone.  These  terms,  though  vague, 
express  perhaps,  as  well  as  it  is  possible  to  do  in  words, 
how  this  voice  deviates  from  the  normal  voice,  but  at 
best  verbal  descriptions  are  faulty,  and  far  inferior  to 
even  a  single  living  illustration.  To  a  physician  accus- 
tomed to  see  these  cases  and  to  obsei've  the  voice,  there 
is  but  little  difficulty  in  at  least  suspecting  the  diagno- 
sis by  this  symptom  alone.  This  nem-asthenic  voice 
somewhat  resembles  the  peculiar  voice  of  the  deaf; 
and  yet  it  is  not  precisely  Uke  that,  and  can  usually  be 


46  NERVOUS   EXHAUSTION. 

distinguished  from  it.  A  neurasthenic  sufferer  may 
have  the  muscles  of  an  athlete,  and  be  so  strong  that  a 
hard  day's  toil  is  but  play,  and  yet  speak  in  a  voice 
which  in  quality  and  volume  of  sound  suggests  the  be- 
girming  of  convalescence  from  a  severe  fever. 

"The  voice,"  says  Emerson,  *'is  a  delicate  index  of 
the  soul,"  and  with  scientific  truth  the  same  philoso- 
pher asserts,  that  the  orator  can  often  tell  by  the  qual- 
ity of  his  own  speech,  at  the  beginning  of  an  oration 
or  sermon,  whether  he  is  or  not  in  a  mood  of  speaking, 
whether  he  is  to  be  eloquent  or  will  utterly  fail. 

A  dissolute  life,  especially  in  women,  always  regis- 
ters itself  in  the  voice,  impressing  a  coarseness  that  in 
its  quahty  is  almost  diagnostic.  The  queens  of  song 
are  never  grossly  impure. 

There  are  a  number  of  cases  of  various  forms  of  dis- 
eases of  the  larynx,  which  have  been  reported  by  Dr. 
Elsberg,  Dr.  Cutter,  and  others,  that  are  clearly  re- 
flected from  the  reproductive  orgaDS,  and  which  yield 
to  treatment  directed  to  these  organs,  when  no  local 
treatment  in  the  lar3aix  is  employed.'  My  friend,  Dr. 
Morrell  Mackenzie,  of  London,  told  me  this  summer 
that  he  did  not  see  these  cases.  The  answer  wliich  I 
gave  was,  that  in  this  country  nervous  irritability  was 
far  more  frequent  than  in  England,  and  that  there  is 
far  more  liabihty  to  reflex  irritations  of  this  kind. 

Deficient  Mental  Control. — Inability  to  concentrate 
the  intellect  on  any  task,  as  in  writing  or  thinking,  is 
a  notable  symj)tom.  The  mind  wanders  away  in  every 
direction,  and  when  brought  back  by  an  effort  of  the 
will,  is  hable  to  be  soon  again  lost  in  reverie. 

In  some  cases,  the  exercise  of  concentration,  or  even 

'  Dr.  Cutter's  paper  on  this  subject  was  read  at  the  meeting  of 
the  American  Laryngological  Association,  and  pubhshed  in  the 
St.  Louis  Medical  and  Surgical  Journal.,  November,  1879. 


SYMPTOMS   OF  NERVOUS  EXHAUSTION.  47 

slight  attention,  is  exceedingly  irksome  and  painful, 
causing  distress  sometimes  in  the  head,  sometimes  in 
the  back  or  extremities,  or  other  parts  of  the  body. 

Inability  to  control  the  mind  shows  itself  in  various 
ways.  An  individual  may  take  up  a  newspaper  or 
book  and  read  over  a  paragraph  a  half-dozen  times, 
without  knowing  anything  about  that  paragraph, 
without  being  able  even  in  a  general  way  to  tell  what 
he  has  been  reading.  Sometimes,  in  discouragement, 
they  throw  down  the  book;  in  despair  they  may  at- 
tempt to  write  a  letter,  and  find  that  they  must  give  it 
up  before  a  single  page  is  completed,  the  mind  wanders 
in  a  sort  of  day  dream  as  far  as  possible  from  the  sub- 
ject to  which  they  would  direct  their  thoughts;  they 
find  that  their  brains  are  masters  and  not  themselves. 
Such  a  person  often  finds  himself  absorbed  in  a  kind 
of  dream,  perhaps  sitting  quite  still  and  forgetful  of 
the  work  to  which  he  has  directed  himself.  A  cler- 
gyman who  consulted  ine  in  the  past  year  for  cere- 
brasthenia,  or  brain  exhaustion,  tells  me  that,  although 
he  can  read  even  profound  treatises,  and  converse  on 
difficult  themes,  yet  if  he  should  attempt  even  to  dic- 
tate and  systematize  a  sermon  he  would  bo  obHged  to 
give  up;  the  very  idea  of  sustained,  directed  thought  at 
once  takes  away  all  his  power. 

Closely  allied  to  this  deficient  mental  control,  and 
indeed  a  part  of  it,  is  what  a  layman,  Mr.  Richard 
Grant  White,  calls  "  Heterophemy, "  that  is,  saying 
one  thing  and  meaning  another,  saying  oftentimes 
directly  the  opposite  to  what  we  meant  to  say;  saying 
precisely  what  we  w^ish  to  avoid;  the  word  we  wish 
shps  in  ahead  of  the  one  that  we  would  bring  to  the 
front.  Persons  in  health  are  frequently  guilty  of  this 
very  interesting  blunder;  but  in  disease  of  the  brain  it 
becomes  a  very  bad  sometimes  very  amusing  as  well 


48  NERVOUS   EXHAUSTION. 

as  very  annoying  symptom.  One  of  my  old  patients 
(the  wife  of  a  patient  just  referred  to),  who  has  both 
brain  exhaustion  and  spine  exhaustion,  sometimes  is 
compelled  to  mention  a  number  of  different  words 
before  she  strikes  the  word  she  wishes.  If,  for  exam- 
ple, she  would  have  a  book,  perhaps  she  would  say 
chair  or  sofa.  She  was  not  troubled  in  this  way  until 
she  became  neurasthenic,  and  since  that  time  she  has 
been  troubled  constantly. 

Mental  Irritability. — A  man  comes  home  at  night 
specially  tired,  and  finds  himself,  or  his  friends  find 
him,  in  a  condition  to  fret  and  worry  and  become  iras- 
cible over  trifles  which,  when  feeUng  well  and  calm, 
would  have  no  influence  upon  him.  The  flurries  of 
domestic  life,  the  cares  of  the  house,  disappointments 
and  vexations,  the  noise  of  play  of  children,  become  a 
source  of  great  distress,  and  he  expresses  this  distress 
in  his  words  and  actions. 

This  behavior  may  be  either  physiological  or  patho- 
logical— the  habit  of  a  perfectly  healthy  man  or  a 
symptom  of  neurasthenia;  appearing  in  one  previously 
good-tempered,  and  associated  with  other  neurasthenic 
symptoms,  it  becomes  of  diagnostic  value. 

Hopelessness. — When  a  patient  is  dying,  in  the  last 
stages  of  consumption  or  cancer,  he  is  often,  if  not 
usually,  hopeful;  and  sometimes  he  does  not  abandon 
the  expectation  of  recovery  even  when  on  the  edge  of 
the  grave.  After  friends  have  given  up  utterly,  and 
the  physician  only  comes  to  relieve,  the  patient  him- 
self is  full  of  hope. 

In  functional  nervous  disorders,  that  are  relievable 
if  not  curable,  the  reverse  phenomenon  is  observed. 
The  patient,  even  in  the  earlier  and  milder  stages,  is 
without  hope,  while  the  friends  laugh  at  his  fears  and 
ridicule  him  for  talking  or  thinking  of  his  symptoms. 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  49 

A  good  example  is  found  in  an  attack  of  sick  headache, 
but  nearly  all  the  neuroses  exhibit  this  phenomenon, 
in  greater  or  less  degree. 

In  organic,  structural,  and  incurable  disease,  such 
as  cerebral  paralysis,  paraplegia,  etc.,  the  sufferer  is 
far  less  Hkely  to  despair  of  relief. 

The  philosophy  of  this  symptom  of  hopelessness  ap- 
pears to  be  similar  to  that  of  morbid  fear — an  instinc- 
tive consciousness  of  inadequacy  for  the  task  before 
us.  We  are  hopeless  because  our  nerve  force  is  so 
reduced  that  the  mere  holding  on  to  hfe  seems  to  be  a 
burden  too  heavy  for  us.  A  certain  amount  of  nerve 
strength  is  necessary  to  supply  the  courage  requisite 
for  simple  existence.  Abstaining  from  dying  demands 
a  degree  of  force  just  as  the  mere  keeping  in  an  erect 
position — standing  up  without  taking  a  single  step— is 
only  possible  to  those  who  have  a  certain  quantity  of 
strength.  Abstaining  from  dying,  hke  abstaining 
from  falling,  is  in  one  respect  a  negation  only,  but 
neither  is  possible  without  an  expenditure  of  force. 

In  our  half-awakened  moments  at  midnight,  a 
slight  noise  causes  the  heart  to  beat  rapidly,  for  we  are 
conscious  of  not  having  full  possession  of  our  powers 
to  meet  any  attack  or  danger.  The  nervously-exhausted 
man  is  always  in  this  state,  physically  insolvent,  and 
unequal  to  the  task  of  living. 

The  despair  of  sea-sickness  well  illustrates  this  phe- 
nomenon. In  the  short  space  of  an  hour,  or  less,  one 
can  be  reduced  from  a  state  of  perfect  bliss  to  perfect 
misery,  simply  from  the  perturbations  caused  by  the 
motion  of  the  vessel. 

One  time,  when  returning  from  England,  our  steamer 

collided  ^vith  a  sailing  vessel  in  such  a  way  and  under 

such  circumstances  as  to  give  just  reason  for  the  belief 

that  we  might  be  in  serious  peril.     In  the  height  of 

4 


50  NERVOUS  EXHAUSTION. 

the  excitement  and  alarm  a  seasick  passenger  came 
out  from  his  room,  where  he  had  been  shut  up  ever 
since  oar  departure,  and  inquired  what  the  trouble  was 
all  about.  He  was  informed  that  our  steamer  was 
leaking  and  that  we  were  fast  sinking.  "  If  that's  all, 
I'll  turn  in  again,"  he  replied,  and  went  back  to  his 
berth,  whence  he  did  not  emerge  until  we  all  landed 
in  New  York. 

In  some  cases  of  neurasthenia,  this  hopelessness  is 
intermittent,  periodic,  hke  attacks  of  inebriety  or 
neuralgia,  and  these  attacks  are  quite  independent  of 
all  external  conditions,  although  they  may  be  excited 
and  modified  more  or  less  by  the  environment.  Hope- 
lessness, as  has  been  said,  is  quite  distinct  from  hypo- 
chondria, defined  and  described  elsewhere.  (See  Chap- 
ter III.) 

Morbid  Fear. — The  emotion  of  fear  is  normal  to  the 
human  mind.  It  is  as  natural  and  as  necessary  to  be 
afraid  as  to  be  courageous.  Fear  is,  indeed,  a  part  of 
the  first  law  of  nature,  self-existence.  This  emotion 
is,  therefore,  physiological,  varying  both  in  degree  and 
kind,  with  race,  sex,  age,  and  the  individual.  In 
neuropathology,  especially  in  the  pathology  of  func- 
tional nervous  diseases,  the  difference  between  health 
and  disease  is  of  degree  rather  than  of  kind;  the  phe- 
nomena that  belong  to  what  we  call  health  passing,  by 
indefinite  and  not  distinctly  defined  gradations,  into 
the  phenomena  of  what  we  call  disease;  j)athology 
being,  in  truth,  as  has  been  said,  but  the  shady  side  of 
physiology. 

Morbid  fears  are  the  result  of  various  functional  dis- 
eases of  the  nervous  system,  and  imply  a  debility,  a 
weakness,  an  incompetency  and  inadequacy,  as  com- 
pared with  the  normal  state  of  the  individual.  A 
healthy  man  fears;  but  when  he  is  functionally  dis- 


SYMPTOMS   OF  NERVOUS   EXHAUSTION.  51 

eased  in  his  nervous  system  he  is  hable  to  fear  all  the 
more;  to  have  the  normal,  necessary  fear  of  his  physio- 
logical condition  descend  into  an  abnormal  pathological 
state,  simply  from  a  lack  of  force  in  the  disordered 
nei'vous  system.  The  debihty  of  the  brain — the  nerve 
impoverishment — renders  it  impossible  to  meet  respon- 
sibility, just  as  paraplegia  makes  it  difficult  or  impossi- 
ble to  walk;  morbid  fear  is  indeed  but  a  psychical 
paralysis,  but  of  a  functional  rather  than  of  an  organic 
nature. 

Patients  of  this  kind  will  walk  up  and  down  before 
a  physician's  office  many  times  before  venturing  to 
enter.  In  a  number  of  instances,  patients  of  mine 
have  told  me  that  they  have  come  to  the  office  and 
gone  away  without  being  able  to  summon  the  courage 
to  ring  the  bell,  and  have  gone  away  and  have  waited 
for  weeks  before  again  making  the  attempt.  These 
confessions  come  oftentimes  from  men  in  middle  life 
who  are  actively  engaged  m  most  important  business 
enteii:>rises,  where  they  are  compelled  all  the  time  to 
meet  and  deal  with  large  numbers  of  people. 

This  timidity  becomes  a  serious  matter  in  business, 
making  success  very  difficult.  One  of  my  patients 
troubled  with  cerebral  exliaustion  (cerebrasthenia),  of 
veiy  large  wealth  and  great  business  exi^^rience,  tells 
me  that,  desiring  once  to  borrow,  on  perfect  security, 
some  money  for  a  certain  business  i)urpose,  he  walked 
several  times  up  and  down  the  front  of  the  office  of 
the  capitalist  whose  aid  he  sought,  before  he  could 
summon  tlie  strength  to  go  in. 

Responsibility  of  any  kind,  without  any  labor,  even 
when  unconscious,  may  powerfully  affect  the  system, 
and  in  various  ways. 

A  very  eminent  theologian  and  [)reacher,  who  con- 
sulted me  three  or  four  years  ago,  told  me  that  when 


52  NERVOUS  EXHAUSTION. 

he  had  charge  of  a  parish,  the  responsibihty  of  sitting 
in  his  pulpit  and  Hsfcening  to  a  traveUing  agent  ex- 
hausted him  more  than  preaching  himself,  for  the 
reason  that  he  continually  feared  that  the  stranger 
would  say  or  do  some  indiscreet  thing. 

Thus  it  comes  to  pass  that  with  the  development  of 
functional  nervous  diseases  in  modern  times,  particu- 
larly with  the  increase  of  neurasthenia  in  its  various 
phases,  there  has  been  an  increase  in  the  forms  of  mor- 
bid fears,  and  in  the  number  of  their  manifestations. 
When  any  special  phase  of  morbid  fear  assumes  a  con- 
siderable frequency  and  consistency,  so  as  to  allow  of 
classification,  it  is  proj^er  and  convenient  to  give  it  a 
special  name  by  which  it  can  be  known,  described,  and 
referred  to.  With  the  understanding  that  these  mor- 
bid fears  are  symptoms  of  diseases,  rather  than  diseases 
of  themselves,  simply  belonging  to  a  large  family  of 
symptoms,  it  is  a  very  important  convenience  to  be 
able  to  recognize  them,  to  interpret  their  meaning,  to 
understand  their  relations  to  the  other  members  of  the 
same  family  of  symptoms,  and  to  be  familiar  with  their 
diagnosis  and  treatment.  It  would  probably  be  a  cor- 
rect statement  to  say  that  no  symptom  of  functional 
nervous  disease  is  so  likely  to  be  overlooked,  or  slighted, 
or  misinterpreted,  or  improperly  named,  as  this  one 
symptom  of  morbid  fear;  it  is  diagnosticated  as  hys- 
teria, hypochondria,  dyspepsia,  imagination,  bilious- 
ness, and  actual  insanity.  Insanity  has,  it  is  true,  its 
morbid  fears,  but  they  are  associated  with  delusions  or 
hallucinations. 

There  are  quite  a  number  of  varieties  of  morbid  fear 
associated  with  cerebrasthenia,  or  brain  exhaustion, 
without  any  hallucinations  or  delusions.  The  patient 
knows  that  there  is  no  just,  objective  ground  for  his 
fear,  but  his  emotional  nature,  under  the  influence  of 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  63 

his  exhausted  nei-vous  condition,  overcomes  his  reason 
and  will. 

A  number  of  years  ago,  I  described  a  form  of  mor- 
bid fear  under  the  term  astixiphohiciy  or  fear  of  light- 
ning, from  the  Greek  astrape  and  phobos,  fear.  Of 
this  disease  I  have  seen  quite  a  number  of  cases,  and 
have  nothing  to  say  in  regard  to  it  beyond  what  has 
been  already  published.  The  leading  symptoms  are 
headache,  numbness  and  pain  in  the  back  of  the  head, 
nausea,  vomiting,  diarrhoea,  and,  in  some  cases,  con- 
vulsions. Tliese  symptoms  are  preceded  and  accom- 
panied by  great  dread  and  fear.  One  of  my  patients 
tells  me  she  is  always  watching  the  clouds  in  summer, 
fearing  that  a  storm  may  come.  She  knows  and  says 
that  this  is  absurd  and  ridiculous,  but  she  declares  she 
cannot  help  it.  In  this  case  the  symptom  was  inherited 
from  her  grandmother;  and  even  in  her  cradle,  as  slie  is 
informed  by  her  mother,  she  suffered  in  the  same  way. 
A  lady  now  under  my  care,  the  wife  of  a  clergyman,  was 
first  attacked  with  these  symptoms  six  years  ago,  in 
comiection  witli  other  symptoms  of  general  neurasthe- 
nic and  uterine  difficulties.  Her  husband  tells  me  that 
on  the  approach  of  a  thunder-storm  he  is  obliged  to  close 
the  doors  and  windows,  darken  the  room,  and  make 
things  generally  inconvenient  for  himself  and  family. 

After  the  reading  of  a  paper  on  this  subject  by  me 
at  the  meeting  of  the  American  Neurological  Associa- 
tion, in  June,  187l>,  Dr.  Webster,  of  New  York,  related 
a  case  of  fear  of  storms,  simply  as  storms,  without 
referi'uce  to  liglitning.  A  woman  forty  yeai-s  of  age, 
whose  mother,  during  pregnancy,  had  been  frightened 
by  a  storm,  suffered  severely  during  the  progress  of  a 
storm,  walking  up  and  down,  in  great  distress,  and 
arousing  the  whole  house  -at  times  appearing  almost 
insane  from  terror. 


54  NERVOUS  EXHAUSTION. 

Westphal  more  recently  has  described  a  form  of 
morbid  fear  under  the  term  agoraj^hobia,  or  fear  of 
places.  This  title,  however,  is  quite  inadequate  to 
express  the  many  varieties  of  morbid  fear  which  the 
expression  fear  of  places  covers.  The  Greek  word 
agora,  from  which  Westphal  derives  his  term,  means 
an  open  square — a  market  place,  a  public  place  where 
assemblies  were  held — and  as  applied  to  the  cases  first 
described  by  him,  the  term  is  practically,  though  not 
etymologically,  a  correct  one,  for  the  fear  of  going 
across  open  squares  or  j^laces,  at  a  distance  from  houses 
to  shoj^s,  was  the  chief  feature  in  all  of  those  cases.' 
This  fear  of  open  squares  or  places  is,  however,  but 
one  of  a  large  number  of  phases  that  the  fear  of  places 
assumes,  as  I  have  elsewhere  described.  In  strictness, 
fear  of  places  should  be  derived  from  the  Greek  word 
topos,  place,  a  generic  term,  while  agora  is  a  special 
kind  of  place;  agorapliohia  would,  therefore,  be  a 
species  of  topophohia.  or  a  general  fear  of  places,  which 
symptom  seems  to  be  capable  of  infinite  variety.  Thus 
one  of  my  cases,  a  gentlemnn  of  middle  life,  could  walk 
up  Broadway  without  difficulty,  because  shops  and 
stores,  he  said,  ofi'ered  him  an  opportunity  of  retreat, 
in  case  of  peril.  He  could  not,  however,  walk  up  Fifth 
Avenue,  where  there  are  no  stores,  nor  in  side  streets, 
unless  they  w^ere  very  short.  He  could  not  pay  a  visit 
to  the  country  in  any  direction,  but  was  hopelessly 
shut  up  in  the  city  during  the  hot  weather.  One 
time,  in  riding  in  the  stage  up  Broadway,  on  turning 
into  Madison  Square,  he  shrieked  with  terror,  to  the 
astonishment  of  the  j)assengers.  The  man  who  jdos- 
sessed   this  interesting  symptom  was  tall,   vigorous, 

'  In  etymological  strictness  agoraphobia  means  fear  of  large  as- 
semblies of  human  beings,  and  not  of  the  place  where  the  people 
meet. 


SYMPTOMS  OP  NERVOUS  EXHAUSTION.  55 

full-faced,  and  physically  and  mentally  capable  of  en- 
durance. He  had,  however,  other  symptoms  of  cere- 
brasthenia.  These  fears  take  opposite  phases;  thus, 
with  one  it  is  impossible  to  go  to  a  certain  place,  where 
he  was  perliaps  first  attacked  with  the  evil  symptoms. 
And  another  finds  it  impossible  or  very  difficult  to  go 
out  of  his  house  to  any  distance  where  business  calls. 
I  have  now  under  care  a  patient  who  for  a  long  time 
has  been  shut  up  in  his  house,  unable  to  go  anywhere, 
simply  from  fear  of  going  anywhere.  For  a  long  time 
he  was  unable  to  come  to  consult  me;  but  now  I  see 
him  regularly;  but  he  did  not,  mitil  lately,  since  he 
has  improved,  go  anywhere  else.  Quite  a  number  of 
persons  I  have  seen  who  find  it  difficult  to  go  on  long 
journeys,  and  if  they  do  go,  must  have  company.  A 
person  wrote  me  from  a  distant  city  in  the  West,  ex- 
pressing a  desire  to  come  and  consult  me,  but  upon 
reaching  a  city  at  some  distance,  was  compelled  to 
return  home  without  reaching  New  York.  All  these 
forms  of  morbid  fear — fear  of  leaving  home,  fear  of 
going  to  any  locality  or  in  any  direction,  fear  of  travel 
— are  properly  varieties  of  topophobia,  the  fear  of  open 
squares  or  places  being  expressed,  though  not  quite 
correctly,  by  cujoraphohia. 

I  have  known  four  persons  who  were  unable  to  cross 
the  Brooklyn  Ferry,  and  all  got  well  in  a  few  weeks 
or  months. 

My  friend,  Dr.  D.  E.  Smith,  of  Bronxville,  N.  Y., 
tells  me  of  a  lady  who  is  unable  to  cross  Harlem  River 
on  the  cai"s,  and  consequently  cannot  visit  New  York 
City. 

I  have  now  under  my  care  a  lady  in  whom  the  topo- 
l)hobia  takes  the  form  of  inability  to  go  to  church.  It 
was  in  churcli  that  she  was  first  taken  with  a  ]>eculiar 
and  hard-to-be- described  lightness  of  the  head;  and  she 


56  NERVOUS  EXHAUSTION. 

now  feels  that  she  could  do  almost  anything  else  rather 
than  attend  church.  Ability  to  do  that  she  would 
regard  as  the  best  and  strongest  sign  of  recovery.  A 
young  business  man,  who  was  first  attacked  with  bad 
symptoms  in  his  factory,  dreaded  to  enter  the  building, 
until,  under  various  treatment,  he  recovered. 

Some  of  the  phases  of  this  morbid  fear  are  very  in- 
teresting and  surprising,  even  to  those  who  are  most 
famihar  with  the  caj^rices  of  the  diseased  nervous  sys- 
tem. I  have  elsewhere  published  a  brief  account  of 
the  physician  who  consulted  me  in  regard  to  himself 
for  long-standing  cerebrasthenia,  one  of  the  symptoms 
of  which  was  inabihty  to  go  away  from  his  home  or 
office,  or  place  where  he  was  stopping,  to  any  consider- 
able distance  in  a  direct  hne.  He  had  the  muscular 
strength  to  walk  twenty  miles,  but  when  summoned 
to  a  patient  was  often  obhged  to  decline  to  attempt  to 
go  even  half  a  mile,  which  was  a  great  astonishment 
to  his  patients,  who  were  aware  that  even  when  un- 
able to  visit  them  he  could  work  all  day  in  his  garden. 
Like  many  of  these  cases  he  had  a  morbid  fear  of 
visiting  the  place  where  he  was  fii'st  attacked  by  any 
of  his  ill  feelings;  thus  he  had  been  at  one  time  pros- 
trated in  Kew  York  City,  and  felt  incompetent  to  come 
here  to  consult  me;  accordingly  I  met  him  by  appoint- 
ment in  a  distant  city.  In  walking  out  with  him  one 
morning,  I  observed  that  he  continually  turned  off  to 
the  side  streets,  so  as  to  keep  at  a  httle  distance  from 
the  hotel  where  he  was  stopping  for  the  day,  and,  on 
my  questioning  liim,  he  said  that  he  could  not  go  more 
than  half  a  mile  in  a  straight  hne,  and  that  therefore 
he  turned  into  the  side  streets  so  as  to  keep  the  hotel 
near  at  hand;  the  result  was  that  we  walked  arm  in 
arm,  circumnavigating  the  hotel  at  a  moderate  distance 
—although  not  always  keeping  it  in  sight.   The  patient 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  57 

•was  not  at  all  wearied,  although  the  walk  was  a  long 
one — in  a  direct  line  perhaps  a  mile  or  two. 

I  have  now  under  care  a  patient  whose  morbid  fear 
takes  just  the  opposite  phase:  he  cannot  go  to  a  certain 
locaUty,  but  can  go  very  near  to  it,  and  beyond  that 
point  liis  own  will  is  often  powerless  to  urge  him  for- 
ward. He  was  first  attacked  while  in  a  lithographic 
establishment, working  at  his  trade;  and  from  that  hour 
he  has  found  it  hard  or  actually  impossible  to  enter 
any  building  devoted  to  that  business.  One  day  he  re 
solved  that  he  would  conquer  what  seemed  to  him  and 
his  friends  a  foohsh  whim,  and  started  out  for  the  shop, 
but  on  arriving  within  sight — about  the  distance  of  a 
block — he  was  compelled  to  stop;  a  cordon  of  police- 
men could  not  have  been  a  more  effective  blockade;  re- 
solved not  to  be  beaten,  he  retired  a  short  distance,  and 
approached  the  building  from  another  direction,  but 
was  again  brought  up  against  the  imaginary  barrier, 
and  so  in  succession  all  the  points  of  the  compass  were 
tried  with  absolute  failure. 

He  had  a  chance  to  work  in  Syracuse,  and  went  to 
the  depot  to  take  the  train  for  that  city,  but  on  enter- 
ing the  station  and  going  up  to  the  office,  he  burst  into 
teare  and  could  not  buy  his  ticket;  he  tried  and  tried, 
and  finally  gave  up  and  returned  home.  He  could 
have  walked  to  Syracuse,  but  he  could  not  reach  out 
his  liand  and  purchase  the  ticket  for  his  fare.  At  an- 
other time  he  succeeded  in  reaching  Cincimiati  in  (juest 
of  employment,  and  was  directed  to  a  lithographic 
establishment  where  he  expected  to  be  employed;  but 
in  spite  of  all  his  rei)eated  trials  he  could  only  come 
within  sight  of  the  building,  and  he  was  forced  to 
return  to  New  York. 

T  have  just  been  consulted  by  a  ]>hysician  who,  as 
one  of  the  effects  and  signs  of  cerebrasthenia,  cannot 


58  NERVOUS  EXHAUSTION. 

at  times  undertake  any  slight  responsibility;  thus  he 
has  sometimes  allowed  a  large  number  of  horse-cars  to 
pass  him  before  he  could  bring  up  the  resolution  to 
jump  on  board  one  of  them;  and  yet  his  muscular 
strength  at  the  time  was  excellent. 

Dr.  Meschede  brought  to  the  attention  of  the  physi- 
cians at  Cassel,  in  Germany,  a  form  of  morbid  fear 
quite  the  opposite  of  what  is  known  as  agoraphobia, 
or  fear  of  open  places.  In  his  case  the  symptom  was 
fear  of  close^  narroiv  places.  The  patient,  a  young 
man  twenty  years  of  age,  was  seized  wnth  a  feeling  of 
giddiness  and  confusion  when  in  a  small,  narrow  room. 
In  the  summer  he  could  not  sleep  in  a  room  at  all,  but 
was  obliged  to  camp  out;  in  winter  he  slept  in  a  large, 
airy  room.  He  was  obliged  to  give  up  his  studies  and 
become  a  farmer.  This  symptom  camiot  be  classed  as 
agoraphobia  at  all,  for  it  is  the  reverse  condition.  It 
belongs  properly  to  what  I  call  topopliohia,  fear  of 
places;  and  is,  like  agoraphobia,  a  species  of  which 
topophobia  is  the  genus. 

At  the  late  meeting  of  the  British  Medical  Associa- 
tion (IS 79),  I  listened  to  a  very  interesting  paper  en- 
titled "  Claustrophobia,"  by  Professor  Ball,  of  Paris. 
This  term  he  applied  to  this  morbid  fear  of  narrow 
places— inabihty  to  stay  within  doors.  Dr.  Ball  related 
a  number  of  cases  illustrative  of  this  phase  of  nervous 
disease,  and  referred  to  Meschede  and  others,  who  had 
studied  the  same  subject.  The  term  Claustrophobia, 
fear  of  close  places,  as  its  derivation  implies,  seems  to 
be  an  excellent  one  and  may  well  be  accepted. 

A  form  of  morbid  fear  that  I  have  lately  described, 
and  of  which  I  have  seen  a  large  number  of  cases,  is 
Anthropopliohia,  derived  from  the  Greek  anthropos, 
man,  and  phohos,  fear.  This  term  applies  to  aversion 
to  society,  a  fear  of  seeing,  encountering,  or  mingUng 


I 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  59 

with  a  multitude,  or  of  meeting  auy  one  besides  our- 
selves. This  phase  of  morbid  fear  has  different  varie- 
ties. In  quite  a  number  of  cases,  this  fear  of  man  is 
so  severe  as  to  compel  patients  to  give  up  business  en- 
tirely; and  I  know  a  number  of  cases  where  men  of 
strong  muscles  and  having  the  appearance  of  great 
physical  strength  have  been  compelled,  through  this 
symptom  alone,  to  withdraw  from  the  occupations  in 
which  they  were  engaged;  they  could  not  face  men, 
deal  with  them,  persuatle  them  to  buy  or  sell,  or  have 
any  influence  over  them;  they  dreaded  to  meet  a 
human  being.  This  form  of  morbid  fear  is  often  ac- 
companied with  turning  away  of  the  eyes  and  hanging 
down  of  the  head,  but  not  necessarily  so,  and  usually 
so  only  in  the  severer  cases.  The  world  over,  aversion 
of  the  eyes  with  a  tmuiing  away  of  the  face  is  an  ex- 
pression of  the  emotion  of  humihty  and  bashfulness, 
that  is,  of  a  feeling  of  weakness  as  com[)ared  with  the 
person  in  whose  presence  we  stand — an  instinctive  and 
involuntaiy  recognition  of  the  fact  that,  for  the  mo- 
ment, our  force  is  inferior  to  his.  In  neurasthenia  this 
same  principle  appears  as  a  pathological  symptom— an 
expression  of  debility,  of  inadequacy,  of  incompetence. 
This  avei-sion  of  tlie  eyes  is  so  constant  a  symptom  in 
these  neurasthenic  patients  that  I  often  make  the  diag- 
nosis as  soon  as  they  enter  the  office,  l)efore  a  word 
has  been  spoken  by  eitlier  party,  and  even  liefore  the 
patient  has  had  time  to  be  seated.  T  have  now  under 
my  care  a  young  man  wlio  is  so  badly  anthiopoj)liobic 
that,  even  when  I  take  his  hea/1  in  my  hands  and  hold 
it  up,  it  is  impossible  to  keep  his  eyes  fixed  on  mine 
for  more  tlian  an  instant.  A  very  intelligent  and  able 
friend,  once  imder  my  professional  care,  displayed  this 
same  characteristic,  and  I  liave  often  talked  with  him 
in  regard  to  it.     This  phase  of  morbid  fear  is  a  very 


60  NERVOUS  EXHAUSTION. 

good  barometer  of  the  condition  of  the  system.  From 
this  alone  we  can  often  judge  whether  the  patient  is 
improving  or  growing  worse.  It  is  a  very  interesting 
symptom.  In  some  cases  I  have  loiown  it  to  come  on 
suddenly,  or  at  least  with  very  little  warning,  save  the 
other  associated  nervous  symptoms. 

This  phase  of  morbid  fear  also  has  its  opposite.  In 
some  persons  there  exists  what  may  be  called  mono- 
phobia, or  fear  of  being  alone.  Some  of  these  persons 
camiot  travel  alone,  but  have  no  difficulty  in  travelling 
if  they  are  in  company  with  some  one.  Sometimes 
they  cannot  walk  the  street  alone,  or  leave  the  house, 
except  in  company.  Dr.  C.  L.  Mitchell  tells  me  of  a 
gentleman  who  was  so  badly  topophobic  that  he  was 
unable  to  leave  his  house  without  company,  and  ac- 
cordingly he  paid  a  man  $20,000  to  be  his  constant 
companion.  There  have  been  men  who,  by  this  symp- 
tom, have  been  kept  as  close  prisoners  as  though 
within  the  walls  of  a  penitentiary 

A  form  of  morbid  fear  that  has  long  been  known  to 
the  profession  is  pathophohia,  or  fear  of  diseases — 
more  commonly  known  as  hypochondriasis.  This  form 
of  morbid  fear  seldom  exists  alone,  but  is  found  in 
company  with  other  symptoms — some  real  disorder  of 
the  nervous  S3^stem,  The  pathophobic  sufferer,  with 
brain  or  stomach,  or  both,  exhausted  for  some  reason, 
may  fear  disease  of  the  heart,  of  the  stomach,  or  of 
the  brain,  or  of  the  reproductive  system,  even  when 
there  is  no  sign  of  disease  except  his  fear.  The  mis- 
take usually  made  in  the  study  of  these  cases  is  to 
assume  that  this  fear  of  disease  is  the  only  symptom 
which  the  patient  has,  and  that  it  is  the  cause  of  the 
disease;  whereas,  usually,  it  is  the  result  of  the  disease 
of  cerebral  exliaustion,  like  the  other  forms  of  morbid 


SYMPTOMS   OF  NERVOUS   EXHAUSTION.  61 

fear,  whatever  the  cause  may  be;  and  as  such  it  should 
be  studied  and  treated.     (See  Chapter  III.) 

There  is  a  manifestation  of  morbid  fear  which  is  not 
uncommon,  and  to  which  we  might  perhaps  give  the 
ievia  pantaphobia,  or  fear  of  everything;  all  responsi- 
bility, every  attempt  to  make  a  change  of  movement 
being  the  result  of  dread  and  alarm.  The  wife  of  one 
of  my  patients  has  a  morbid  fear  in  reference  to  one 
of  her  sons,  a  lad  of  about  fifteen  years  of  age;  and  so 
distressed  is  she  by  it  that  she  cannot  allow  him  to  go 
out  of  the  house,  or  out  of  her  sight,  fearing  lest  he 
may  be  kidnapped,  or  some  harm  may  come  to  him, 
as  in  the  case  of  Charlie  Ross.  The  poor  fellow  is  thus  ♦ 
kept  a  prisoner  most  of  the  time,  and  the  whole  family 
is  disturbed  and  annoyed.  He  must  remain  in  the 
city  during  the  summer,  as  she  cannot  allow  him  to 
leave  town;  and  at  no  season  can  he  go  anywhere 
unless  accompanied  by  his  tutor. 

A  lady  now  under  my  treatment,  who  is  also  astra- 
phobic,  tells  me  that  she  is  afraid  to  go  into  the  street, 
to  do  any  shopping,  or  attend  to  any  business;  that  it 
is  an  affliction  for  her  to  see  a  physician;  eveiything  is 
a  dread  to  her,  even  when  there  is  no  draft  mad«^  uj)on 
her  physical  strength. 

The  expi'ession,  phobophobia,  fear  of  fears,  might 
possil)ly  apply  to  a  certain  class  of  nervous  patiejits 
who  fear  they  may  feai-,  provided  they  make  an  at- 
tempt to  move  or  go  in  any  direction  where  their  mor- 
bid ear  is  in  the  way;  they  are  afraid  even  when  they 
do  and  say  nothing.  These  persons  fear  when  they 
aie  entirely  still  and  inactive,  from  a  fear  that  if 
they  attemj)t  to  do  anything  they  will  be  attacked 
with  their  especial  morbid  fear.  One  of  my  patients 
— a  stout  and  largo  man — in  addition  to  topoi)hobia 
(fear  of  places)  had  at  one  time  a  fear  of  committing 


62  NERVOUS   EXHAUSTION. 

some  crime  that  would  disgrace  him.  He  was  ashamed 
of  his  fear;  he  could  not  help  it,  although  he  has  now 
entirely  recovered. 

Mifsopliohia,  fear  of  contamination,  lately  described 
by  Dr.  Hammond,  comes  under  this  head;  the  results 
of  the  treatment  showing  very  clearly  that  it  is  symp- 
tomatic of  a  similar  or  analogous  condition  of  the 
brain.  In  those  cases  there  were  no  hallucinations  or 
delusions. 

In  one  of  the  cases,  there  was  an  iiTesistible  desire 
to  wash  the  hands;  the  patient  spent  a  large  part  of 
her  time  in  that  occupation.  One  of  the  patients 
gashed  her  hands  as  many  as  two  Imndred  times  a  day. 

I  lately  saw,  in  consultation  with  Dr.  Cai'penter,  a 
lady  who  was  fuU  of  morbid  fears,  some  of  them  of 
the  most  absurd  character;  she  feared  storms  and  was 
in  apprehension  of  earthquakes,  and,  in  certain  crises, 
when  at  her  worst,  she  could  not  let  her  husband  set 
out  on  a  short  journey  on  a  matter  of  business.  In 
this  case,  the  tendency  to  morbid  fear  was  hereditary: 
her  father  being  a  most  striking  instance  of  mysopho- 
bia,  having  such  dread  of  dust  that  he  never  sits  down 
in  a  cl^ir  until  he  has  well  dusted  it,  no  matter  in 
whose  presence  he  may  be.  He  will  even  get  up  in 
the  night  and  dust  all  his  clothes  with  great  thorough- 
ness, holding  them  out  of  the  window  so  that  the  room 
may  not  be  defiled. 

Siderodromopliohia. — "This  is  a  form  of  intense 
spinal  irritation,  described  by  Rigler  of  Germany, 
coupled  with  a  hysterical  condition,  and  morbid  disin- 
clination for  work,  which  is  the  result  of  shock,  and 
occurs  among  railroad  men;  most  commonly  seen  in 
cases  of  railway-engine  mechanics  who  hav^e  some 
altered  nerve  condition,  or  irritation  of  the  nerve- 
centres.    It  is  the  perpetual  jarring,  shaking,  and  noise 


SYMPTOMS   OP   NERVOUS   EXHAUSTION  63 

which  lead  by  degi'ees  to  this  change,  and  which  under 
the  influence  of  some  unexpected  shock  completely 
breaks  up  the  nervous  equilibrium." 

I  have  very  lately  seen  two  cases  where  the  morbid 
fear  was  directed  against  diTinken  men.  I  have  had 
under  care  a  young  man  of  intelligence  and  culture, 
who  is  neurasthenic  in  many  important  features;  and, 
indeed,  has  been  an  unusual  sufferer  from  this  trouble, 
who  is  so  afraid  of  meeting  or  coming  in  contact  with 
a  drimken  man  in  the  street,  that  he  will  stay  in  the 
house,  even  when  necessary  for  him  to  be  out,  rather 
than  go  out  and  run  the  risk  of  meeting  such  a  person. 

On  the  feny  boat,  if  lie  sees  a  drunken  man,  he  goes 
to  the  extreme  end  of  the  boat,  to  get  as  far  as  he  can 
from  the  object  of  ten-or.  He  tells  me  that,  one  time, 
getting  on  a  street  car,  there  was  a  man  only  shghtly 
intoxicated;  he  could  not  remain  on  the  car,  but  was 
obhged  to  leave  it  before  he  had  nearly  an-ived  at  his 
destination.  This  fear  seems  to  be  a  fear  of  a  row— of 
some  trouble  which  the  drunken  man  may  cause, 
rather  than  any  fear  of  the  man  himself. 

In  the  case  of  this  young  man,  the  difficulty  is 
periodic.  There  is  a  certain  street  down-town,  in  the 
vicinity  where  intoxicated  men  are  often  found,  where 
his  business  sometimes  compels  him  to  go.  He  can 
go  tln-ough  this  street  before  three  o'clock  in  the  after- 
noon, but  not  after  that  time. 

In  regard  to  all  these  different  forms  of  morbid  fear, 
by  whatever  name  they  are  known  or  described,  these 
general  pro])ositions  are  tiiie  and  verifiable: 

First. — Tlieso  morbid  fears  are  symptomatic  of  func- 
tional, never,  or  rarely,  of  organic  diseases.  Tlie  ex- 
istence of  any  of  tliose  symptoms,  in  a  doubtful  rase 
of  diagnosis,  would  alone  almost  establish  the  nature 
of  the  disease,  or  enable  us  to  give  the  casting  vote. 


64  NERVOUS   EXHAUSTION. 

The  best  test  of  skill  in  the  practice  of  neurology  is 
in  making  a  differential  diagnosis  between  functional 
and  organic  diseases  in  their  early  stages;  for  this 
cause  alone  morbid  fears  demand  close  attention. 

While  it  is  possible  for  hysterical  and  neurasthenic 
symptoms  to  appear  and  maintain  themselves,  more 
or  less,  in  organic  diseases,  yet  these  symptoms  of 
morbid  fear  are  not  found,  according  to  my  observa- 
tion, in  what  we  call  organic  or  structural  diseases  of 
the  brain  or  spinal  cord;  it  is  strange  that  they  are 
not,  but  the  fact  as  here  related  is  verifiable. 

They  are  not  found  in  insanity  itself,  save  as  delu- 
sions or  hallucinations,  and  the  habit  of  calling  them 
forms  of  mania  or  delusion  is  not  based  on  fact  or  a 
right  study  of  these  cases.  I  observe  that,  even  now, 
some  forms  of  morbid  fears  are  classed  under  insanity, 
or  mania  of  some  kind,  even  when  there  are  no  delu- 
sions or  hallucinations.  When  the  insane  have  morbid 
fears,  such  as  I  have  described,  or  very  many  others 
which  they  may  have,  and  do  have,  as  we  all  know, 
they  are  delusions  out  of  which  they  cannot  be  rea- 
soned, and  are  a  part  of,  and  in  harmony  with  other 
delusions  of  the  insane.  But  in  all  the  cases  to  which 
I  have  here  referred,  there  are  no  delusions  and  no 
hallucinations  whatever;  the  patient  is  as  well  aware 
of  his  troubles  as  his  friends  are,  and  is  as  anxious  to 
get  rid  of  them  as  he  would  be  of  a  sick  headache, 
fever,  or  paralysis;  but  he  is  unable  to  shake  them  off 
until  the  exhausted  brain,  of  which  they  are  the  du'ect 
result,  is  strengthened  by  hygiene  and  time  and  treat- 
ment. 

Second. — These  symptoms  may  come  on  suddenly, 
in  some  cases  almost  instantaneously,  and  when  once 
they  appear,  they  may  exist  for  months  and  years, 
varying  in  intensity  at  different  times,  Hke  other  symp- 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  65 

toms  of  cerebrasthenia,  with  which  they  are  often  as- 
sociated. 

Third. — These  morbid  fears  are  very  frequently, 
though  not  always  or  necessarily,  the  result  in  whole 
or  part  of  disorder  of  the  reproductive  system. 

Excess  in  the  male  in  the  natural  or  unnatural  ways, 
or  prolonged  and  teasing  continence  united  with  sexual 
excitation,  and  in  the  female,  various  slight  and  super- 
ficial uterine  erosions,  or  displacements  or  lacerations, 
are  the  common  provoking  causes  of  these  morbid 
fears,  especially  in  constitutions  where  the  nervous 
diathesis  predominates. 

These  fears  may  exist  long  after  the  local  difficulty 
has  been  cured;  in  this  respect  these  symptoms  follow 
the  law  of  the  nervous  symptoms  witli  which  they  are 
so  often  associated.  Some  of  these  cases  are  anaemic, 
but  the  majority  are  not  so,  and  many  are  models  of 
physical  strength. 

Fourth. — The  morbid  fears  rarely  exist  alone.  They 
almost  always  appear  in  connection  with  other  symp- 
toms of  neurasthenia,  either  myelasthenia,  exliaustion 
of  the  spine,  or  cerebrasthenia,  exhaustion  of  tlio  brain; 
most  frecjuently  the  latter.  I  think,  indeed,  tliat  I 
liave  never  seen  a  case  of  morbid  fear,  such  as  I  have 
liere  described,  that  existed  alone,  without  some  one 
accompanyijig  neurasthenic  symjttom,  or  many  such 
symptoms.  In  some  cases,  I  admit,  these  accompany- 
ing symptoms  are  few  and  slight,  and  can  be  ascer- 
tained only  by  careful  study. 

Among  those  associated  symptoms  may  be  men- 
tioned palmar  hyperidrosis,  flushing  of  the  face,  a  feel- 
ing of  profound  exhaustion,  insonmia,  hopelessness, 
shooting  pains  in  the  extremities,  excess  of  oxalates 
and  urates  in  the  urine,  heaviness  of  the  loins  and 
hmbs,  dilated  pupils,  local  spasms  of  muscles.     Only 


66  NERVOUS  EXHAUSTION. 

rarely,  however,  is  there  a  complete  picture  in  which 
all  these  symptoms  are  represented.  Like  all  these 
symptoms  of  neurasthenia,  morbid  fears  very  often 
occur  in  those  of  great,  even  enormous  muscular 
strength  and  endurance;  many  of  them  can  walk  and 
work  all  day  with  muscle  and  with  brain;  but  in  the 
presence  of  their  special  fears  they  are  as  infants. 

A  very  frequent  accompanying  symptom  is  dizziness. 
Many  of  these  cases,  when  they  approach  the  object 
of  dread,  or  even  think  of  approaching  it,  are  seized 
with  vertigo— sometimes  with  less  defined  abnormal 
sensations.  I  have  seen  three  cases  where  an  epigas- 
tric spasm  appears  on  attempting  or  even  thinking  of 
doing  anything  which  is  a  dread.  I  have  now  under 
care  a  patient  who  tells  me  that  he  has  a  spasm  in  the 
stomach  whenever  he  thinks  of  doing  anything  where 
he  fears  a  failure.  He  describes  it  as  a  sudden  sinking 
— a  falling,  somewhere  between  the  base  of  the  lungs 
and  the  navel. 

This  patient  has  also  a  large  array  of  correlated 
nervous  symptoms,  such  as  sweating  of  the  hands, 
twitching  of  the  eyelids,  mental  depression,  etc.  One 
of  these  cases  had  this  phase  of  spasm — sinking  in  of 
the  stomach;  while  at  school  it  would  come  upon  him 
whenever  he  was  called  upon,  or  feared  he  might  be 
called  upon,  to  read;  even  the  thought  of  responsi- 
bility, though  it  might  be  in  the  remote  future,  brought 
on  the  attack. 

For  convenience  of  reference,  this  classification  of 
morbid  fears  may  be  thus  tabulated: 

AsTRAPHOBiA— Fear  of  lightning. 

ToPOPHOBiA — Fear  of  places;  a  generic  term,  with 
these  subdivisions: 

Agoraj)hobia — Fear  of  open  places. 
Claustrophobia — Fear  of  naiTow,  closed  places. 


SYMPTOMS  OF  NERVOUS   EXHAUSTION.  67 

Anthropophobia — Fear  of  man;  a  generic  term,  in- 
cluding fear  of  society. 

Gynephobia — Fear  of  woman. 

Monophobia— Fear  of  being  alone. 

Pathophobia — Fear  of  disease,  usually  called  hypo- 
chondriasis. 

Pantaphobia — Fear  of  everything. 

Phobophobia — Fear  of  being  afraid. 

Mysophobia— Fear  of  contamination. 

Flush  imj  and  Fidget hies.s.—Vaimnis  of  this  class 
oftentimes  easily  flush  and  easily  faint;  the  inhibitory 
action  of  the  symi)athetic  is  readily  interfered  with  by 
any  slight  emotion.  Fidgetiness  and  nervousness,  in- 
ability to  keep  still — a  sensation  that  amounts  to  pain 
— is  sometimes  unspeakably  distressing.  Although  it 
cannot  be  defined,  it  may  be  an  accompaniment  of 
growing  pains,  and  is  one  of  the  myriad  results  of 
spinal  irritation.  Sometimes  in  writing,  the  hand  and 
arm  become  so  nervous  and  fidgety  that  to  continue 
writing  would  be  the  severest  torture.  When  the  legs 
feel  this  way,  the  sufferer  nuist  get  uj)  and  walk  or 
run,  even  though  he  be  debilitated  and  is  made  worse 
by  severe  exercise.  A  gentleman  once  under  my  care 
could  not  sit  still  in  the  chair  long  enough  to  take  an 
application  of  electricity. 

Freqiiciif  Blnshiny  — A  very  common  effect  of  nerv- 
ous exhaustion,  in  both  sexes,  is  frecpient  and  severe 
blushing  from  the  sligbest  i)ossil)l(^  mental  or  physical 
causes,  and  extending  sometimes,  not  ()nly  over  the 
face,  forehead,  and  ears,  but  down  the  neck,  and  ap- 
])anMitly  over  other  portions  of  the  body.  Suddenly 
meeting  any  onC;  a  stranger  or  acquaintance,  the  bear- 
ing of  an  unexi)ected  noise,  the  taking  of  food  or  diink 
into  the  stomach,  esi)ecially  when  rapidly  swallowed, 
any  stooping,  or  straining,  or  any  slight  muscular  or 


68  NERVOUS   EXHAUSTION. 

mental  exertion,  may  bring  on  this  unpleasant,  per- 
plexing, and  annoying  symptom.  In  some  cases  the 
symptom  appears  without  any  objective  cause  what- 
ever; the  person  may  be  sitting  all  alone,  and  the  face, 
under  some  thought,  or  fear,  or  anxiety,  or  feehng  of 
responsibility,  may  become  as  red  as  though  suddenly 
entering  company. 

This  blushing  is  accompanied  sometimes  by  blinking 
of  the  eyes,  smarting  or  stinging  of  the  eyelids,  twitch- 
ing of  some  of  the  muscles  of  the  face,  confusion  of 
mind  and  stammering  of  speech,  which,  like  the  red- 
dening of  the  face,  are  beyond  the  control  of  the  will. 
Infants  under  one  year  never  blush,  for  they  do  not 
feel  that  sensitiveness  in  regard  to  what  others  think 
of  them,  that  is  needful  to  excite  blushing. 

Some  of  the  peculiarities  of  blushing  are  very  inter- 
esting. A  lady  patient  of  mine,  who  is  of  a  very  sensi- 
tive organization,  tells  me  that  when  she  blushes,  little 
red  spots,  resembhng  measles,  first  appear  on  the 
cheeks,  and  then  extend  down  over  the  neck;  in  a 
moment  these  coalesce  into  a  diffused  redness. 

Sir  James  Paget,  while  examining  the  spine  of  a  girl, 
noticed  that  a  big  splash  of  red  appeared  on  lier  cheek; 
this  was  followed  by  others  over  her  neck  and  face. 
On  questioning  her  mother  in  regard  to  it,  she  said  that 
the  peculiarity  Avas  inherited  from  her,  and  in  answer- 
ing this  question  she  blushed  like  her  daughter. 

Blushing  is  a  physiological  phenomenon;  but,  like 
many  other  physiological  phenomena,  may  become 
pathological,  both  causes  and  results  of  disease.  When 
it  becomes  excessive,  as  in  the  above  description,  it 
may  be  regarded  as  pathological.  As  a  symptom  of 
neurasthenia,  it  is  more  common  and  more  distressing 
than  is  generally  believed.  I  have  seen  very  strong, 
vigorous  men,  who  have  large  muscular  power  and 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  69 

great  capacity  for  physical  labor,  who,  while  in  a 
neurasthenic  state,  would  blush  like  young  girls. 
Some  young  men  are  so  harassed  by  this  symptom  that 
they  cannot  meet  young  ladies  in  the  street  or  go  into 
any  company  of  their  own  sex  without  blushing  ex- 
cessively; and  on  this  account  they  frequently  keep 
away  from  society  altogether. 

This  symptom  does  not  occur  in  the  modest,  diffi- 
dent, and  retirmg  alone;  the  bold,  the  energetic,  and 
the  determined — those  who  can  and  do  push  their  way 
in  hf  e — may  become  victims  of  this  disorder.  It  is  said 
that  Tliomas  Brown,  the  author  of  Religio  Medici,  was 
a  sufferer  in  this  way,  \'Miile  this  veiy  paragraph  is 
being  constructed,  I  am  consulted  by  a  young  physi- 
cian of  intelligence,  ability,  and  education,  who,  al- 
though suffering  from  otlier  neurasthenic  symptoms 
of  at  least  disagreeable  cliaracter,  yet  complains  more 
of  this  blushing  than  of  all  other  symptoms  combined, 
and  for  this,  chiefly,  came  to  ask  my  advice. 

Like  many  of  the  other  phenomena  of  neurasthenia, 
this  blushing  may  come  and  go — lasting  for  months 
and  years,  and  disappearing  as  suddenly  as  it  came. 
Like  sick  headache,  it  has  a  tendency  to  disappear  as 
we  advance  in  life.  It  is,  also,  as  amenable  to  treat- 
ment as  other  symptoms  of  neurasthenia. 

Insomnia. — The  different  phases  of  insomnia  in 
neurasthenic  patients  are  exceedingly  interesting. 

One  man  finds  no  difficulty  in  getting  to  sleep  on  re- 
tiring, but  soon  awakes,  and  nnist  remain  awake  for 
the  rest  of  the  night.  Another  man  rolls  and  tumbles 
for  horn's  before  he  falls  into  oblivious  slumber,  but 
when  once  asleep  does  not  usually  wake  until  morning. 
I  was  recently  consulted  for  a  case  of  insonmia  of 
many  years'  duration,  where  there  had  never  been  any 
difficulty  in  sleeping  after  getting  to  sleej). 


70  NERVOUS  EXHAUSTION. 

Other  sufferers  report  that  they  sleep  in  fragments 
— oases  of  repose  in  a  desert  of  dreary  wakefulness— 
but  bad  dreams  constantly  harass  them  so  that  in  the 
morning  they  are  less  rested  than  they  should  be. 
Why  a  bad  dream  should  be  a  bad  symptom  is  not 
quite  clear.  Vn.ij  a  man  disturbed  by  indigestion,  or 
exhausted  nervously  by  excitement  late  in  the  even- 
ing, should  dream  of  snakes  and  monsters  instead  of 
green  fields  and  gardens,  of  death  and  murder  instead 
of  deUghtful  society  and  experiences,  has  perliaps  only 
this  general  explanation,  that  the  normal  action  of  the 
cerebral  cells  is  designed  to  be,  in  the  main,  pleasura- 
ble, and  that  mental,  hke  physical  pain,  is  a  symptom 
of  something  abnormal.  It  is  also  a  question  how  far 
dreams  are  pathological.  It  would  seem  tliat  in  per- 
fect health — if  there  be  such  a  state — one  might  dream 
even  unpleasantly;  and  yet  there  is  no  doubt  that  sav- 
ages, and  farmers,  and,  in  general,  those  who  live  out- 
doors, depending  on  their  muscles  for  their  subsistence, 
dream  far  less  than  the  in  door  brain-workers  My 
guide  in  the  woods  of  Maine  and  northern  New  Hamp- 
shire teUs  me  that  he  very  rarely  dreams,  and  one  cool, 
phlegmatic  maJi,  whom  I  met  in  that  region  last  sum- 
mer, assui'ed  me  again  and  again  that  he  never,  in  aU 
his  hfe,  had  a  dream  that  he  could  recall;  and  with 
that  class,  as  a  rule,  dreams  of  any  kind,  good  or  bad, 
are  exceptional. 

Some  neurasthenic  patients  can  only  sleep  by  night 
— never  by  day,  however  wearied.  Others  can  sleep 
by  day;  often  faU  to  sleep  when  they  especially 
desire  to  keep  awake,  but  at  night  toss  in  painful  ac- 
tivity. 

Physical  exercise  also  acts  very  capriciously  with  dif- 
ferent persons.  Thus  one  of  my  patients  tells  me  that  if 
he  takes  a  long  walk  in  the  evening,  he  is  more  restless 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  71 

than  usual  that  night;  and  yet  he  is  a  very  strong 
man,  capable  of  much  physical  and  mental  toil. 

One  peculiarity  of  sleeplessness  is,  that  the  mind  is 
intensely  and  painfully  active  in  many  directions,  or 
in  some  one  direction,  very  often  over  the  events  of 
the  day,  and  all  the  efforts  of  the  sufferer  to  slow  down 
the  wheels  of  thought  are  inoperative;  the  patient 
dozes  all  night,  or  a  good  portion  of  the  night,  living 
over  again  in  a  most  distressing  way  the  experiences 
of  waking  liours.  Nervously  exhausted  patients  often 
wake  up  in  the  moniing,  feeling  almost  as  tired  as 
wlien  they  went  to  bed  in  the  night;  may  have  slept 
perhaps  several  hours,  but  they  have  not  rested  by  the 
sleep;  they  get  up  tired  and  discouraged.  All  patients 
of  this  kind  generally  sleep  more  than  they  believe; 
they  say  that  they  get  no  sleep,  when  they  do  perhaps 
lose  themselves  several  hours  every  night;  it  is  impos- 
sible, as  a  rule,  to  convince  such  people  that  they  sleep 
at  all.  It  is,  however,  one  of  the  interesting  facts  of 
the  human  constitution,  tliat  these  sufferers  can  go  so 
long,  can  live  so  many  years,  be  active  in  business  and 
social  life,  with  so  little  sleep. 

Drowsiness  is  the  opposite  symptom,  and  is  experi  • 
enced  by  persons  whose  symptoms  in  other  respects 
are  very  much  the  same  as  those  of  the  sl(Y'i)less, 

One  of  my  patients,  a  clergyman,  long  suffering 
from  cerebrastlienia,  tells  me  that  at  one  time,  if  he 
imdertook  to  read,  lie  would  very  soon  feel  sleepy, 
lemain  so  for  half  an  hour,  wake  uj),  attemi)t  to  read, 
and  again  feel  sleepy;  this  symptom  more  than  any 
other  comp('ll(!(l  bim  to  n'sign  his  charge.  In  som(^ 
cases  this  drowiiiess  does  not  come  to  positive  sleep; 
the  patient  is  simply  dull,  heavy,  sleepy,  without  hav- 
ing the  ability  to  get  asl«'ep.  It  has  been  supposed 
that  this  drowsiness  was  a  symptom  of  amemia  of  the 


72  NERVOUS  EXHAUSTION 

brain,  while  wakefulness  was  a  symptom  of  hyperae- 
mia  of  the  brain;  but  the  truth  is,  that  both  conditions 
may  be  relieved  oftentimes  by  the  same  treatment. 
On  this  subject,  my  friend  Dr.  Lente  gives  me  this 
experience:  He  was  in  consultation  with  the  late  Dr. 
George  T.  Elliott,  of  this  city,  over  a  case  of  severe 
hemorrhage,  which  caused  the  patient  to  be  very  sleep- 
less from  profound  ana3mia.  Dr.  Lente  suggested  the 
use  of  bromide  of  potassium.  Dr.  Elhott  objected,  on 
the  theory  that  the  bromides  tended  to  diminish  the 
quantity  of  blood  in  the  brain;  bromide,  however,  was 
used,  and  it  made  the  patient  sleep  in  spite  of  anaemia. 
All  close  observers  must  have  had  experience  very 
much  the  same. 

Tenderness  of  the  Teeth  and  Gums. — Attacks  of  ten- 
derness of  all  the  teeth,  accompanied  by  a  whitish 
appearance  of  the  gums,  I  have  noticed  in  nervous 
exhaustion.  In  these  attacks,  which  may  result  from 
over- work,  or  excess,  all  the  teeth  may  be  very  tender 
OQ  pressure,  although  none  of  them  are  decayed. 
Here,  then,  is  another  opportunity  to  study  with  the 
naked  eye  the  pathology  of  spinal  irritation.  In 
nervous  exhaustion,  whether  complicated  with  anaemia 
or  not,  there  may  be  tender  uess  of  any  part  of  the 
body  or  of  the  whole  body.  Tenderness  of  the  head  is 
cerebral  irritation;  of  the  spine,  spinal  irritation;  of 
the  tip  of  the  spine,  coccyodynia;  of  the  breast,  irrita- 
ble mammae;  of  the  ovaries,  irritable  ovaries;  of  the 
teeth  here  described,  dental  irritation ;  and  so  on  of  the 
womb;  and  the  jDathology  of  any  one  of  these  symp- 
toms is  probably  the  pathology  of  all. 

Nervous  Dyspepsia  {Dyspepsie  Asthenique). — In 
cases — not  a  few — nervous  dyspepsia  is  the  first  notice- 
able symptom  of  nervous  exhaustion — the  earliest 
sign  that  the  body  is  giving  way;  and  for  years,  the 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  73 

stomach  may  be  fmictionally  disordered  before  the 
brain,  or  spinal  cord,  or  other  parts  or  organs,  show 
signs  of  yielding.  The  tine  philosophy  is,  that  ner- 
vous dyspepsia  is  a  symptom  of  the  same  general 
pathological  condition  as  all  the  orders  of  symptoms 
here  noted,  and  it  may  follow  or  accompany  as  well 
as  lead  this  multitudinous  army.  A  literary  gentle- 
man whom  I  once  met  gave  a  history  of  nervous  ex- 
haustion from  over-confinement,  that  after  some  years 
broke  out  through  the  pneumogastiic  nerve,  causing 
profound  and  obstinate  dyspepsia  that  for  a  long  time 
made  him  a  complete  invalid;  the  symptoms  were  al- 
most as  bad  as  those  of  cancer  of  the  stomach,  and  yet 
the  disturbance  was  entirely  functional,  and  the 
patient  improved.  Flatulence,  with  annoying  rumb- 
ling in  the  bowels,  these  patients  complain  of  very 
frequently;  also  nausea  and  diarrhoea. 

I  am  accustomed  to  diagnosticate  nervous  dyspepsia 
from  other  forms  of  nervous  dyspepsia  depending  on 
inflammation  or  other  chronic  disturbances,  by  the 
following  considerations: 

First,  in  nervous  dyspepsia,  the  patients  feel  woi'se 
when  the  stomach  is  empty,  and  are  relieved  by  eat- 
ing. Patients  of  this  class  have  the  greatest  distress 
before  meals,  or  when  a  meal  is  long  delayed;  even 
over-eating  is  a  relief  to  them.  With  these  persons, 
mental  or  physical  labor  on  a  perfectly  empty  stomach 
is  very  apt  to  cause  distress— pain  in  the  eyes,  pain  in 
the  head,  general  nervous  distress  all  over  the  body, 
and  j)ain  in  the  stomach  itself;  indeed,  there  is  no  jiart 
of  the  organism  that  will  not  suffer  when  mind  or  body 
is  much  exercised  on  a  i)erfectly  empty  stomach. 

Secondly,  the  symptoms  of  nervous  dyspepsia  are 
very  capricious,  coming  and  going  without  traceable 
cause. 


74  NERVOUS  EXHAUSTION. 

Thirdly,  nervous  dyspepsia  is  most  commonly  found 
with  the  nervous  diathesis,  and  is  apt  to  be  associated 
with  other  nervous  symptoms  in  other  parts  of  the 
body.  In  some  cases,  nervous  dysiDepsia  is  a  forerun- 
ner of  a  long  list  of  nervous  symptoms  through  all  the 
different  organs,  as  the  eyes,  the  ears,  the  bi-ain,  the 
spine,  and  reproductive  apparatus.  In  some  cases,  it 
takes  the  place  of  many  of  these  symptoms,  being 
better  when  they  are  worse,  and  worse  when  they  are 
better. 

Fourthly,  nervous  dyspeptics  are  relieved  by  reme- 
dies that  have  a  sedative  and  tonic  effect  in  general, 
without  any  special  reference  to  the  stomach.  Elec- 
tricity is  one  of  the  very  best  for  all  forms  of  this  dys- 
pepsia. The  bromides,  that  have  no  special  effect 
upon  the  stomach  so  far  as  we  are  informed,  are  very 
well  adapted  to  relieve  nervous  dyspepsia. 

Deficient  Thirst,  and  Capacity  for  Assimilating 
Fluids. — Quite  recently,  a  physician  who  consulted  me 
in  regard  to  himself,  called  my  attention  to  the  highly 
interesting  fact  that  he  rarely  drank  water  either  at 
meals  or  between  meals;  and  he  stated  that  the  aver- 
age quantity  of  liquid  that  he  consumed  was  far  below 
the  normal  standard.  Investigation  of  other  cases  of 
neurasthenia  has  convinced  me  that  this  deficiency  of 
thirst  is  one  of  the  symptoms  of  that  state,  and  it 
would  appear  that  it  is  not  an  unusual  symptom,  but 
exists  in  not  a  few  cases;  there  are  many  who  for 
years  have  a  poor  appetite  for  fluids,  as  they  have  a 
poor  appetite  for  solid  food;  they  live  on  a  small  quan- 
tity of  liquid,  and,  perhaps,  without  suspecting  it,  until 
their  attention  is  directed  to  the  fact.  There  are  those 
who  find  that,  if  they  take  much  liquid,  the  stomach 
suffers,  even  when  little  or  no  solid  food  is  mingled 
with  it.     One  advantage,  with  some  disadvantages,  of 


SYMPTOMS   OF   NERVOUS  EXHAUSTION.  75 

the  free  use  of  beer  with  our  German  friends  is  in  the 
quantity'  of  fluid  that  they  thereby  imbibe — the  water 
of  the  drink  more  than  the  alcohol.  Drinking  milk 
has  a  similar  advantage. 

"VVTien  we  remember  that  the  body  is  composed 
mostly  of  water,  we  can  easily  see  that  there  is  a  dan- 
ger of  starving  for  want  of  simple  liquid,  just  as, 
under  the  influences  of  our  civilizatiou,  we  are  starving 
for  want  of  fatty  food. 

There  is  no  question  that  the  Europeans,  who  are 
far  less  nei^ous  than  the  Americans,  use  far  more 
liquid  nourishment;  and  it  is  a  fact,  more  and  more 
impressed  on  my  mind,  that  many  neui'asthenic 
patients  are  very  temperate,  if  not  total  abstainers, 
and  some  abstain  even  from  tea  and  coffee. 

Desire  for  Stimulants  and  Narcotics. — When  the 
nervous  system  loses,  through  any  cause,  much  of  its 
jiei-vous  force,  so  that  it  cannot  stand  upright  with 
ease  and  comfort,  it  leans  on  the  nearest  and  most 
convenient  artificial  support  that  is  capable  of  tempo- 
rarily i^ropping  up  the  enfeebled  frame.  Anything 
that  gives  ease,  sedation,  oblivion,  such  as  chloral, 
chloroform,  opium,  or  alcohol,  may  be  resorted  to  at 
first  as  an  incident,  and  finally  as  a  habit.  Such  is 
the  philosophy  of  many  cases  of  opium  or  alcohol  ine- 
briety. Not  only  for  the  relief  of  pain,  but  for  the 
relief  of  exliaustion,  deeper  and  more  distressing  tban 
pain,  do  Ijoth  men  and  women  resort  to  the  drug  shop. 
I  count  this  as  one  of  the  great  causes  of  the  recent 
increases  of  oj)inin  and  alcohol  inebriety  among  women. 
Fi-equently  an  inlierited  tend(>ncy  to  inel)riety  is  utterly 
latent,  and  does  not  break  out  until  affliction,  or  some 
form  of  wony  or  distress,  robs  the  brain  of  its  nerve- 
force.  Very  many  cases  illustrative  of  this  hav(?  been 
published  by  my  friend  Dr.  T.  D.  Crothei*s,  of  Hart- 
ford, Ct. 


76  NERVOUS  EXHAUSTION. 

One  sign  of  neurasthenia,  especially  of  an  acute  at- 
tack, is  inability  to  bear  certain  kinds  of  stimulants 
and  narcotics  to  which  patients  have  been  accustomed; 
thus  patients  have  told  me,  that  during  illness  of  any 
kind,  they  were  obliged  to  suspend  smoking;  they  say 
that  tobacco  makes  them  sick.  This  happens  to  those 
who  have  been  accustomed  to  use  large  quantities, 
both  chewing  and  smoking.  As  they  regain  their 
strength,  they  also  regain  their  power  of  using  stimu- 
lants. 

The  opposite  condition  is  also  found;  and  a  person 
when  depressed  can  sometimes  bear  immense  quanti- 
ties of  alcohol,  who  in  health  is  capable  of  drinking 
but  veiy  little.  It  happens  sometimes  in  hysteria,  for 
example,  that  alcoholic  drinks  can  be  consumed  very 
freely  indeed,  although  the  patient  is  very  weak  and 
nervous  in  every  respect. 

A  hay-fever  patient  of  mine — a  frequent  sufferer 
from  that  disease — who  was  accustomed  to  take  sev- 
eral large  doses  of  stimulants  before  an  attack  to  pre- 
vent nervous  exhaustion,  told  me  that,  while  in  that 
state,  he  would  drink  almost  any  amount  of  alcoholic 
hquors  without  being  affected  thereby.  This  form  of 
idios3^ncrasy  against  alcohol  would  appear  to  be  a  dan- 
gerous state,  as  it  may  lead  to  inebriety. 

Ahnormalities  of  the  Secretions. — In  nervous  ex- 
haustion, the  eyes  may  become  moistened  more  read- 
ily than  in  health,  and  under  a  very  slight  emotion  of 
f)leasure  or  of  pain.  The  flood-gates  seem,  as  it  were, 
to  stand  ajar;  and  on  trifling  agitation  the  tears  flow 
forth.  In  grave  cerebral  disease,  this  symptom  is 
common  enough,  but  in  functional  disease — simple 
nervous  exhaustion — it  is  even  more  common;  and 
"  softening  of  the  brain  "  is  feared. 

In  nervous  debility,  also,  the  sebaceous  glands  may 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  77 

refuse  to  do  their  duty;  the  hair  and  beard  become  dry 
and  stiff,  and  much  pomade  is  needed.  The  hair  then 
falls  off  or  becomes  gray  in  patches. 

Abnormal  dryness  of  the  Skin,  Joints,  and  Mucous 
Membranes. — In  sonxe  cases  of  neurasthenia  the  skin 
of  the  whole  body  is  unnaturally  dry;  this  is  especially 
and  most  reacHly  noticed  in  the  hands,  but  all  parts  of 
the  surface  may  present  this  peculiarity.  A  scaliness 
or  scui-finess  may  accompany  this  dryness,  as  though 
there  were  a  deficiency  of  fluids  and  of  sebaceous 
secretion.  There  would  also  appear  to  be  a  relation 
between  this  condition  and  a  disinchnation  to  drink, 
or  use  fluids  freely. 

A  young  lady  of  twenty-one,  in  addition  to  many 
other  neurasthenic  symptoms,  had  dryness  of  the  scalp, 
eyes  and  ears,  especially  in  the  moraing;  her  eyes  and 
ears  would  be  dry  and  hot,  and  in  the  ears  a  thin 
skin  would  form,  and  fine  scales  would  be  thrown  off. 
These  s>^nptoms  were  not  constant;  they  would  leave 
entirely  for  a  number  of  days,  and  then,  without  any 
apj)arent  cause,  return — tlius  following  the  law  of  all 
other  symptoms  of  neurasthenia 

Dryness  of  the  joints  is  also  observed  in  the  nei-v- 
ously  exhausted.  How  the  joints  may  suffer  in  grave 
spinal  diseases,  sucli  as  ataxy,  is  well  known;  but  in 
these  functional  maladies,  of  wliich  neurasthenia  is  a 
type,  tlie  joints  may  suffer,  though  in  a  less  severe 
mamier.  Deficiency  of  the  secretion,  with  dryness 
and  cracking  sound  on  movement,  I  have  noticed  in  a 
number  of  cases;  in  one  striking  case  of  nnisician's 
cramp,  cracking  of  the  joints  is  noticed  in  the  affected 
fingers. 

Sweating  Hands  and  Feet,  tvifh  Redness  {Palmar 
Hyjieridrosis).— SweatinQ  of  the  hands— of  the  palmar 
surface,  or  of  the  entire  hand — palmar  hyperidi'osis — 


78  NERVOUS  EXHAUSTION. 

is  a  symptom  of  neurasthenia  at  once  so  interesting 
and  so  frequent  that  I  wonder  that  the  hterature  of 
the  subject  is  so  meagre. 

This  phenomenon — abnormal  perspiration  of  the 
hands — is  certainly  more  common  in  males  than  in 
females,  although  it  occurs,  as,  indeed,  all  forms  of 
hyperidrosis  occur,  in  both  sexes.  The  milder  phases 
are  common  enough,  but  there  are  severe  manifesta- 
tions that  this  symptom  may  assume,  which  seem 
well-nigh  beyond  behef.  Thus  a  young  man  now 
under  my  care  is  so  distressed  thereby  that  he 
threatens  suicide  unless  he  is  permanently  cured.  In 
his  case,  there  are  various  evidences  of  a  bad  inheri- 
tance, a  poor  constitution,  although  this  palmar  sweat- 
ing is  just  now  the  only  very  annoying  expressioji  of 
the  depraved  diathesis.  A  young  lady  in  the  northern 
part  of  the  State  is  compelled  to  take  a  number  of 
handkerchiefs  with  her  when  she  goes  to  school,  and 
on  her  retm^n  they  are  aU  saturated  from  the  excessive 
perspiration  of  her  hands.  My  friend.  Dr.  Josiah 
Koberts,  of  this  city,  teUs  me  that  in  a  similar  case, 
lately  brought  to  his  attention,  there  was  clear  proof 
of  uterine  disease. 

The  intimate  relation  of  this  symptom  to  the  nervous 
system  is  shown  in  many  striking  facts.  Thus  one 
young  man  who  consulted  me  would  be  attacked  peri- 
odically— at  ten  and  four  o'clock — and  whenever  he 
was  at  sea  the  symptom  would  utterly  leave  him.  In 
one  of  my  cases,  the  slightest  emotion  would  instantly 
satui'ate  the  hands  as  thoroughly  as  dipping  them  in  a 
pail  of  water.  The  effort  to  shake  hands  is  sufficient 
to  produce  this  effect.  Eedness  of  the  whole  hand- 
erythema — sometimes  attends  this  palmar  sweating, 
and  in  one  of  my  cases  the  ears  are  as  red  as  the 
hands. 


SYMPTOMS   OF   NERVOUS  EXHAUSTION.  7{) 

One  of  my  patients,  now  restored  to  health,  tells  nie 
that  his  luind-sweating  was  so  prof  use  that,  in  writing, 
he  was  forced  to  kee})  blotting  paper  beneath  his  hand 
to  absorb  the  moisture. 

I  have  been  consulted  by  a  physician  who  is  so  mucli 
affected  with  palmar  hyperidrosis  that  a  pair  of  gloves 
will  not  List  him  more  than  ten  days,  and  his  shoes 
also  wear  out  rapidly. 

Sdl ivat iuH .  —  Dvyness  of  tlie  mouth,  through  sup- 
pression of  the  salivaiy  secretion,  is  often  noticed,  both 
as  an  effect  of  emotion  and  as  an  effect  of  nervous 
substitution:  the  opposite  condition,  salivation,  is  not 
so  common. 

A  year  ago,  an  intelligent  physician  informed  me 
that,  at  one  time,  while  in  a  neurasthenic  state,  he 
went  to  bed,  and  l)y  an  effort  of  the  will,  as  he  ex- 
pressed it,  brought  on  free  salivation.  Subsequent 
nights  the  same  effect  occui-red,  contrary  to  his 
wishes,  and  it  was  some  time  before  he  was  restored 
to  his  normal,  original  condition. 

Teudrnicss  of  tlio  Spine  {Sphial  Trrifafioii),  and  of 
the  v'liolc  Body  {Cknicral  llijpord'sthi'sia). — When  the 
spine  is  so  tender  as  to  become  an  important  and  per- 
maueut  afllirlion,  and  to  overshadow  other  symptoms 
of  the  neurasthenic  state,  it  is  called  spinal  irritation; 
but,  strictly,  it  is  a  symptom,  like  cerebral  irritation, 
not  proi>erly  a  disease  as  such,  although,  as  a  matter 
of  convenience,  there  can  be  no  harm  practically  in 
describing  it  as  a  disease.  In  regard  to  tliis  symptom 
of  nervous  exhaustion,  these  i)oints  are  noticeable: 
First,  its  great  frcMpiency  in  the  higher  classes,  espec- 
ially among  women.  I  suppose  if  one  should  go 
through  Fifth  Avenue,  of  New  York  City,  and  exam- 
ine the  spines  of  all  the  ladies  between  fifteen  and 
forty-five  years  of  age,  he  would  find  in  qmte  a  per- 


80  NERVOUS   EXHAUSTION. 

centage  of  cases  that,  at  times,  there  would  be  tender- 
ness either  of  the  whole  length  of  the  spine,  or,  more 
likely,  at  certain  points,  as  the  nape  of  the  neck,  and 
between  the  shoulder-blades,  and  on  the  middle  lum- 
bar vertebrae.  Crawling,  creeping,  and  burning  sensa- 
tions often  accompany  this  tenderness.  This  condition 
would  be  found  at  times  in  those  who  do  not  call 
themselves  invalids,  and  who  are  not  under  medical 
treatment.  It  would  furthermore  be  found  that,  with 
some  of  these  cases,  there  would  be  tenderness  of  the 
scapula  or  hip  bones,  of  the  breast  bone,  and,  indeed, 
of  the  whole  surface  of  the  body.  This  general  hyper- 
sesthesia,  like  the  local  hyperaesthesia  of  the  spine, 
appears  and  disappears  under  any  subjective  or  objec- 
tive exciting  causes,  and  is  attended  usually  by  a  feel- 
ing of  debility,  and  oftentimes,  though  not  always,  by 
backache,  headache,  insomnia,  and  mental  depression. 

The  transient  nature  of  this  symptom  of  spinal  and 
general  irritation  is  shown  by  the  fact  that  it  may 
disappear  often  after  a  single  application  of  electricity. 
Many  women  always  have  spinal  irritation  during  the 
period  of  menstruation.  Spinal  irritation — tenderness 
on  pressure — is  not  the  only  symptom  of  spinal  ex- 
haustion; it  is  but  one  of  many  symptoms  of  that 
state.  In  some  cases  of  spinal  exhaustion,  also,  there 
is  no  tenderness  of  the  spine  on  pressure. 

Coccyodynia. — A  very  common  and  sometimes  most 
distressing  form  of  spinal  irritation  is  what  is  caUed 
coccyodynia — that  is,  tenderness  with  pain,  and  some- 
times severe  neuralgia  at  the  tip  of  the  spine,  what  is 
called  the  coccyx.  This  is  far  more  common  with 
women  than  with  men;  indeed,  in  man  it  very  rarely 
occurs.  It  almost  always  accompanies  irritations  of 
other  portions  of  the  spine. 

One  of  the  symptoms  of  this  form  of  spinal  irritation 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  81 

is  a  feeling  as  though  the  spine  were  too  long;  when 
sitting,  this  feeUng  is  a  distressing  one. 

Peculiarities  of  Pain  in  the  Back. — In  neurasthenia, 
all  parts  of  the  back  may  be  the  seat  of  pain,  although 
certain  districts  are  more  affected  than  others.  There 
may  be  tenderness  when  there  is  no  pain,  and  con- 
versely pain,  even  severe  pain,  when  there  is  no  ten- 
derness. There  may  be  much  distress  in  the  loins  and 
over  the  hips,  when  careful  examination  shows  no 
tenderness  anywhere. 

Tliis  pain  in  the  hips  and  loins  is  something  quite 
different  from  ordinary  neuralgia  or  sciatica;  it  rather 
resembles  muscular  rheumatism  or  a  common  cold, 
and  is,  indeed,  often  confounded  with  one  or  both  of 
these  diseases,  even  by  able  diagnosticians.  The  ha- 
bility  to  confound  initation  of  the  upper  part  of  the 
spine  at  the  nape  of  the  neck  with  rheumatism  is  very 
great;  the  symptoms,  indeed,  are  quite  the  same — 
pains,  stiffness,  aching,  inability  to  move  the  head  with- 
out discomfort.  Sometimes  this  condition  perfectly 
simulates  wry-neck,  and  is  mistaken  for  it.  One  of 
the  very  ablest  neurologists  in  Germany,  on  being  con- 
sulted by  a  case  of  irritation  in  the  upper  part  of  the 
spine,  made  diagnosis  of  rheumatism,  and  treated  the 
patient  accordingly.  This  back  pain,  and  the  tender- 
ness that  may  or  may  not  accompany  it,  fluctuates  hke 
all  these  neurasthenic  symptoms:  to-day  they  are 
present  in  fuU  force,  to-morrow  they  are  all  gone,  but, 
on  any  provocation,  are  liable  to  return.  They  fly 
about  in  every  direction;  now  just  below  tlie  shoulder- 
blade;  now  in  the  centre  of  the  spine;  and  at  another 
time  between  the  shoulder-blades,  or  in  the  middle 
lumbar  region;  sometimes  with  heat  and  burning,  at 
others  with  biting  penetrating  sensations,  or  a  feeling 
as  though  ants  were  crawling  just  under  the  skin. 


82  NERVOUS  EXHAUSTION. 

Heaviness  of  the  Loins  and  Limbs. —One  of  the 
most  frequent  complaints  among  the  neurasthenic 
(myelasthenic  form)  is  heaviness  and  vague  aching  of 
the  loins  and  limbs,  and  sometimes  of  the  whole  body. 
This  is  a  symptom  hard  to  defiae  in  exact  words,  but 
it  is  very  common,  and  it  is  a  cause  of  great  distress. 
This  symptom  is  quite  apt  to  follow  over  physical 
exertion,  as  in  walking  or  standing,  but  may  come  on 
without  any  apparent  or  special  exciting  causes.  This 
feeling  so  closely  resembles  rheumatism  that  it  is  often 
confounded  with  that  affection  by  those  who  are  un- 
familiar with  neurasthenia,  and  even  one  well  ac- 
quainted with  nervous  exhaustion  in  all  its  forms, 
might,  on  first  being  called  to  a  patient,  mistake  this 
heaviness  and  aching  for  a  common  cold,  or  for  a 
rheumatic  attack.'  I  have  lately  been  consulted  by  a 
gentleman  suffering  from  myelasthenia,  where  this 
aching  of  the  lower  part  of  the  back  and  loins  is  almost 
the  only  subjective  symptom.  In  sexual  exhaustion, 
pains  in  the  loins  and  limbs,  not  amounting  to  neu- 
ralgia, but  sufficient  to  be  a  severe  annoyance,  are 
frequent  enough,  but  they  are  not  restricted  to  the 
sexual  variety  of  neurasthenia. 

There  would  seem  to  be  a  degree  of  truth  in  the 
suggestion,  which  has  often  occurred  to  me  in  study- 
ing these  cases  of  pain  in  the  back  and  loins  and  the 
lumbar  region,  that  they  were  to  men  what  so-called 
spinal  irritation  is  to  women.  It  may  be  said  that 
this  condition  is  to  spinal  irritation  what  hypochondri- 
asis is  to  hysteria.  The  distinction  is  not  absolute,  for 
both  sexes  have  the  same  group  of  symptoms.  There 
would  appear  to  be  more  cases  of  men  who  have  these 
symptoms — pain  in  the  back  and  loins,  from  neuras- 

'  How  the  symptoms  of  ataxy  have  been,  and  are,  mistaken  for 
rheumatism  is  well  known  to  the  physician. 


SYMPTOMS  OP  NERVOUS  EXHAUSTION.  83 

thenia,  without  any  tender  points,  any  irritation  of  the 
spine— than  of  women.  When  females  have  pain  and 
weakness  in  the  back,  they  are  more  hkely  to  have 
great  tenderness  on  pressure.  This  distinction  is,  I 
beHeve,  verifiable.  Erb,  in  his  chapter  on  this  subject, 
raises  the  same  query. 

Shooting  Pains  simulating  those  of  Ataxy. — If  there 
be  any  difference  between  the  familiar  shooting,  light- 
ning-like pains  in  the  extremities,  that  have  so  long 
been  considered  as  peculiar  to  ataxy,  and  the  shooting 
pains  of  neurasthenia,  I  have  not  been  able  as  yet  to 
find  it  out.  Generally,  these  neurasthenic  pains  are 
milder  than  those  of  ataxy,  but  this  average  fact  does 
not  interfere  with  the  fact  of  observation,  that  this 
difference  in  degree  is  not  of  itself  sufficient  to  make 
it  possible  to  establish  the  differential  diagnosis;  for 
the  shooting  pains  of  ataxy  are  by  no  means  always 
severe,  and  in  many  cases  of  the  disease  do  not  exist 
at  all.  The  mistake  of  writers  in  so  strenuously  insist- 
ingi  on  the  diagnostic  importance  of  these  shooting 
pains  has  been,  and  is,  the  source  of  terri1)le  annoyance 
to  physicians,  especially  who  hai)pen  to  be  themselves 
sufferers  from  these  neurasthenic  symptoms. 

The  same  remark  api)lies  to  fibrillaiy  contractions, 
which  have  been  looked  upon  as  indicating  muscular 
atrophy,  but  whicli,  as  I  have  elsewhere  stated,  may 
exist  as  one  of  the  many  symptoms  of  neurasthenia. 

Fodalgia  (Pdiu-  iti  the  Feet). — One  of  the  symptoms 
of  ataxy  in  the  early  stages  is  a  feeling  of  numbness 
of  the  feet. 

Sometimes  there  is  a  feeling  as  tliough  straw  were 
at  the  bottom  of  their  feet,  or  as  of  walking  on  velvet, 
or  rubber,  or  wool.  A  feeling  of  heat  and  burning  is 
also  noticed;  and  both  in  neurasthenia  and  in  ataxia 
it  comes  from   the  spine.     It  has,  however,  a  very 


84  NERVOUS  EXHAUSTION. 

different  significance;  in  one  case  it  means  an  organic, 
and  in  the  others  a  nervous,  functional  disease. 

In  some  cases,  there  are  painful  spots  on  the  feet, 
either  on  the  sides  or  at  the  bottoms.  These  spots  are 
more  painful  from  pressure  of  the  boot  or  shoe;  they 
are  felt  even  when  in  bare  feet  or  in  slippers. 

Pains  of  the  feet  may  be  observed  in  persons  not 
specially  nervous,  but  they  are  to  be  found  also  as 
symptoms  and  results  of  neurasthenia. 

There  is  little  question  but  that  in  some  cases  they 
are  reflected  from  the  stomach  or  genital  apparatus. 

Tremulous  and  Variable  Pulse  and  Palpitation  of 
the  Heart  {Irritable  Heart).— In  the  nervous,  the 
rapidity  and  quality  of  the  pulse-beats  may  vary  in 
many  ways  during  the  process  of  counting.  Fre- 
quently the  pulse  of  the  nervously  exhausted  is  com  • 
pressible,  and  almost  always  it  is  more  rapid  than 
normal,  ranging  between  75  and  90,  frequently  going 
up  to  95,  100,  or  110  and  more.  In  exceptional  in- 
stances, nervous  exhaustion  has  a  very  slow  puis©,  in 
the  neighborhood  of  -10  or  less,  or  there  may  be  alter- 
nations between  a  very  high  and  a  very  low  pulse. 

The  heart  is  quite  apt  to  be  very  irregular  and  irrita- 
ble in  many  of  these  cases.  It  beats  perceptibly  and 
painfully,  not  only  under  excitement,  but  upon  even 
a  thought  of  responsibihty— of  undertaking  anything 
which  requires  exertion:  even  when  sitting  quite  still. 
It  is  so  powerfully  affected  by  the  mind,  so  intimately 
under  the  influence  of  the  emotions,  that  I  have 
almost  abandoned  the  habit  of  examining  the  pulses 
of  my  patients,  on  a  first  visit,  for  the  reason  that  I 
learn  almost  nothing  by  such  examinations.  The  ex- 
citement of  seeing  a  stranger  always  puts  the  pulse  up 
so  much  that  I  can  hardly  tell  what  the  actual  condi- 
tion is.    Those  affected  thus  often  suppose  that  they 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  85 

have  organic  disease  of  the  heart,  and  sometimes 
worry  more  over  this  symptom  than  all  of  the  other 
symptoms  combined. 

In  some  cases,  noises  in  the  ears  rise  and  fall  with 
the  beating  of  the  heart,  and  when  the  pulse  is  veiy 
high  the  noises  are  very  loud  and  distressing.  In 
some  cases,  also,  the  pulse,  a  part  of  the  day,  will  be 
very  high  indeed,  and  again,  in  a  few  hours,  very 
slow.  There  is  pain  and  oppression  in  the  region  of 
the  heart. 

[Dr.  S.  (t.  Webber'  has  recently  made  some  interest- 
ing observations  on  the  use  of  the  sphygmograph  in 
neurasthenic  patients,  and  divides  them  into  three 
classes:  "  First,  those  in  which  the  vascular  tension 
is  nearly  or  quite  normal.  There  are  a  few  such,  who 
seemingly  have  been  only  temporarily  run  down,  and 
quickly  recover. 

"Another  class  may  be  formed  of  those  who,  at  first, 
show  a  decid<ul  loss  of  vascular  tone,  who,  after  a 
course  of  treatment,  regain  a  normal  tension.  These 
usually  rocovor  in  a  longer  or  shorter  time.  Those 
whom  I  hav(?  had  under  my  care  have  not  always  re- 
gained health  while  under  observation,  but  I  have  had 
subsequent  iufoimation  from  many  who  liave  contin- 
ued to  steadily  gain,  and  liave  recovx'red  a  fan-  amount 
of  health. 

"A  third  class  are  those  whose  vascular  tone  is  very 
nuich  below  normal,  who  show  a  variable  condition 
of  the  vaso-motor  system,  sometimes  ai)parcnt]y  gain- 
ing a  little,  then  losing  ground,  but  on  the  whole  mak- 
ing no  sul^stantial  progress.  Many  of  tliese  have  a 
hereditary  tendency  to  an  unstable  nervous  equilib- 

'  A  Stnily  of  Arti'i-inl  Tension  In  Ni'urnstlu'nia.  Jinstun  Medi- 
cal and  fSu/yicul  Jmniud,  May  :id,  l^by. 


86  NERVOUS  EXHAUSTION. 

rium,  or  there  is  some  condition  of  the  system  that 
reacts  unfavorably  upon  the  circulation.  These  cases 
do  not  improve  much,  and  whatever  is  gained  is  of 
very  doubtful  permanency;  there  is  a  lack  of  vascular 
stabihty  which  is  unfavorable  to  recovery, 

"  I  have  had  a  few  cases  where  the  earher  tracings 
showed  a  nearly  normal  condition  of  the  blood-vessels, 
but  later  tracings  were  less  favorable.  In  such  cases 
there  has  usually  been  some  cause  to  which  such  un- 
favorable change  could  be  ascribed.  One  patient  was 
doing  well,  gaining,  with  a  good  pulse;  her  son-in-law, 
upon  whom  she  was  partially  dependent,  met  with  an 
accident  which  was  nearly  fatal.  This  shock  com- 
pletely upset  her,  and  the  vessels  afterwards  showed  a 
very  great  lack  of  tension. 

"Some  of  the  worst  cases  show  a  gi'eat  variation 
within  a  few  minutes,  one  tracing  being  only  shghtly 
variant  from  the  normal,  the  next,  taken  within  five 
minutes,  showing  a  great  loss  of  tension." 


No.  2. 


Tracing  No.  1  was  taken  from  one  of  his  neuras- 
thenic patients,  suffering  from  nervous  depression, 
insomnia,  headache,  etc.,  and  shows  marked  loss  of 
tension.  The  second  tracing  was  taken  some  weeks 
subsequently,  after  the  patient  had  materially  im- 
proved in  all  her  symptoms,  and  shows  a  nearly  nor- 
mal tension.     Dr.  Webber  concludes  that  the  sphyg- 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  87 

mograph  is  an  aid  in  determining  the  amount  of 
exhaustion;  and  by  comparisons  of  tracings  taken  at 
intervals,  the  progress  of  the  patient  towards  recovery 
can  be  estimated.  A  fictitious  gain  can  be  recognized, 
as  distinguished  from  a  real  gain;  no  gain  being  per- 
manent unless  the  tension  of  the  arteries  is  perma- 
nently restored.  A  patient's  future  prospects  of  health 
can  be  calculated  witli  more  certainty  by  an  occasional 
use  of  the  sphygmograph.  It  is  sufficient  to  take  a 
tracing  once  in  two  or  four  weeks.] 

Local  Spasms  of  Muscles  {Tremors). — WHiat  are 
called  "fibrillary  contractions,"  and  which  sometimes 
occur  in  progressive  muscular  atrophy,  are  also  noticed 
in  the  various  shades  of  nerv^ous  exhaustion.  An  in- 
dividual muscle  or  part  of  a  muscle  may  twitch  occas- 
ionally or  frequently,  so  as  to  cause  considerable  an- 
noyance, and,  in  some  cases,  unnecessary  anxiety.  As 
these  vibrations  occur  in  the  orbicularis,  and  other 
muscles  of  the  face,  these  spasms  are  very  familiar; 
they  come  and  leave  without  warning,  and  suddenly, 
lasting  all  the  way  from  a  few  minutes  to  hours,  or 
even  days.  They  are  not  very  bad,  sometimes,  nor 
especially  troul)lesome,  excei)t  when  they  become 
chronic,  and  tlie  twitdiing  extends  to  other  nuiscles 
of  the  face.  Tliis  result  is  exceptional;  and  so  far  as 
I  have  observed,  chronic  facial  spasm  does  not  occur 
in  tliose  who  have  nervous  exhaustion.  I  was  once 
conversing  on  nervous  diseases  with  a  well-known 
physician,  when,  all  at  once,  the  orbicularis  of  one  of 
his  eyes  l)egau  to  twitcli  vigort)Usly;  he  said  it  was 
the  fii"st  time  in  his  life  that  h(3  liad  experienced  any- 
thing of  the  kind;  he  regarded  the  use  of  tobacco  as 
the  i)robabl(;  cause. 

The  stomach,  in  nervous  dyspepsia,  may  be  the  seat 
of  similar  spasms,  which  may  follow  any  excitement 


88  NERVOUS  EXHAUSTION. 

or  emotion,  as  of  fear  or  responsibility.  A  sensation 
like  that  of  a  reverse  aura  seems  to  go  downward  to 
the  pit  of  the  stomach  from  the  nerve-centres,  and  ex- 
cites spasms,  apparently,  of  the  muscles  of  the  stom- 
ach itself. 

Nervously  exhausted  patients  are  sometimes  attacked 
with  sudden  tremors  These  tremors  come  on  under 
excitement,  sometimes,  and  then  leave  without  any 
apparent  exciting  cause.  In  some  cases,  they  seem  to 
be  periodic,  at  least  in  a  degree,  like  chills,  in  malaria. 
Shght  exertion,  and,  especially,  unusual  exertion,  may 
bring  them  on. 

Dysphagia  {Difficulty  of  Swallowing). — Dysphagia  is 
sometimes  a  result  of  neurasthenia  I  have  seen  it  in 
severe  cases  of  hay-fever,  where  there  is  great  prostra- 
tion. I  have  seen  it  also  as  a  chronic  condition  in 
persons  who  are  exceedingly  nervous — coming  and 
going — made  better  or  worse,  apparently,  by  no  objec- 
tive cause  that  can  be  ascertained. 

Convulsive  Movements^  especially  on  going  to  Sleep, 
— Nervous  sufferers,  just  as  they  are  dropping  off  to 
sleep,  are  sometimes  suddenly  and  jDainfully  awakened 
by  a  violent,  spasmodic  movement  of  an  arm,  or  leg, 
or  of  the  whole  body.  This  appears  without  any 
warning,  and  is  most  likely  to  occur  when  preceded  by 
unusual  excitement  or  fatigue.  In  some  cases,  there 
wiU  be  a  recurrence  of  these  spasms,  so  that  much 
difficulty  is  experienced  in  getting  to  sleep.  I  have 
known  instances  where  the  whole  body  seemed  to  be 
thrown  off  the  bed,  or,  rather,  the  sensation  was  as 
though  the  body  were  projected  upward.  This  symp- 
tom is  not  so  alarming  as  some  of  those  who  experi- 
ence it  believe.  It  indicates  an  exhausted,  a  worn 
condition  of  the  nervous  system;  but  it  is  not  as 
ominous  for  evil  as  many  other  phenomena  that  belong 


SYMPTOMS   OF  NERVOUS  EXHAUSTION.  89 

to  the  nervously  exhausted  state.  A  friend  of  mine — 
a  pubhc  speaker,  constantly  before  audiences,  and 
always  at  work — with  a  frame  of  unusual  size  and  an 
extraordinary  capacity  for  enduring  mental  excitement 
and  toil  —tells  me  that  with  all  his  vigor  he  lias  been 
aiuioyed  by  these  jerkings  on  falling  to  sleep,  although 
he  has  no  other  evidence  of  neurasthenia. 

It  is  probable  that  these  convulsive  symptoms  on 
dropping  to  sleep  are  the  effect  and  sign  of  congestion 
in  the  exhausted  nerve  ceiitres,  and  occur  while  pass- 
ing out  of  the  waking  into  the  sleeping  condition,  be- 
cause the  inhibitory  or  controlling  power  of  the  wak- 
ing state  is  removed. 

I  know  of  a  gentleman,  now  quite  advanced  in  life, 
who,  for  half  a  century  or  more,  has  been  regularly 
affected  in  this  way,  and  to  a  degree  almost  past 
credence.  Every  night  for  an  hour  or  more — some- 
times for  two  or  three  hours — he  will  have  a  succession 
of  these  startings  and  jerkings,  which  are  accompanied 
by  a  gininting  or  groaning  sound  quite  distinct  from  a 
snore,  and  which  is  audible  in  the  adjoining  room. 

Cramps. — One  of  the  symptoms  of  certain  phases  of 
neurasthenia  is  the  occurrence  of  cramps;  usually  in 
the  calf  of  the  leg,  and  more  frequent  at  night. 
Sometimes  these  pains  are  so  severe  as  to  awaken  the 
patient  out  of  a  sound  slumber,  and  are  only  relieved 
by  severe  rubbing,  or  by  energetic  movements. 

In  some  cases,  these  ci'amps  are  felt  as  soon  as  one 
gets  fairly  in  bed  and  asleep. 

Special  Idiosyncrasies  in  Regard  to  Food,  Medicine, 
and  E.rtcnial  Trrifaiifs.—Whi^n  the  nervous  system 
becomes  exhausted,  it  is  apt  to  develop  various  idio- 
syncrasies not  before  observed;  some  of  them  are  of 
high  interest.  Opium,  for  exami)le,  is  likely  to  aggra- 
vate insonmia  in  many  neurasthenic  patients,  instead 


90  NERVOUS  EXHAUSTION. 

of  putting  them  asleep,  unless,  indeed,  very  large 
doses  are  used.  Formerly  opium  was  our  chief — 
almost  our  only  dependence  when  we  wished  to  put 
one  asleep.  Now  we  scarcely  think  of  using  it  for 
that  purpose  in  the  treatment  of  the  nervous,  except 
when  there  is  severe  pain  to  be  relieved.  Opium  for 
the-  nervously  exhausted  prevents  sleep  almost  as 
much  as  coffee.  So  frequent  is  this  idiosyncrasy,  that, 
were  it  not  for  the  bromides  and  cannabis  indica  and 
electricity,  we  should  be  utterly  disarmed  in  the  pres- 
ence of  these  cases. 

In  regard  to  alcohol,  some  are  so  susceptible  that  a 
drop  of  any  form  of  liquor  is  instantly  and  injuriously 
felt  in  some  part  of  the  system.  Others,  on  the  other 
hand,  lose  all  unpleasant  susceptibility  to  alcohol,  and 
can  bear  it  in  incredible  quantities,  and  may  sometimes 
be  profited  by  it.  A  lady  whom  I  know  had  for  years 
been  passing  through  a  series  of  symptoms  of  nervous 
depression  that  our  most  honored  experts  had  failed  to 
relieve.  One  day  an  ignorant  and,  I  believe,  irregular 
practitioner  came  into  her  house,  and  without  inquir- 
ing into  her  case  at  all  told  her  in  a  rough  and  authori- 
tative manner  to  get  the  best  of  claret  and  drink  it 
freely.  The  chance  shot,  sent  in  the  dark  and  without 
aim,  struck  the  very  centre  of  the  bull's-eye;  the  lady 
bought  the  best  of  claret,  drank  it  with  astonishing 
freedom,  and  found  that  it  did  for  her  what  the  best 
expert  skill  of  our  city  had  failed  to  do. 

Coffee  often  acts  badly  with  these  cases.  A  young 
man  who  consulted  me  for  exhaustion,  with  nervous 
dyspepsia,  told  me  that  if  he  drank  a  single  cup  of 
coffee  in  the  morning  he  was  unable  to  attend  to  his 
business  with  comfort,  and  could  not  calculate  or  write 
correctly.     Many  also  are  kept  injured  by  tea. 

Incidentally  I  wiU  remark  that  the  development  of 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  91 

idiosyncrasies^  through  nervous  sensitiveness^  acquired 
or  inherited,  is  the  reed  philosophy  of  hay  fever — a 
malady  which,  as  I  have  shown  in  my  work  on  that 
subject,  has  increased  as  culture  and  civilization  have 
increased,  and  which  is  found  usually  in  those  who 
have  had  some  other  nervous  symptoms.     As  an  effect 
of  this  inherited  or  acquired  nervo-sensitiveness,  there 
appears  in  one  person  an  idiosyncrasy  against  bright 
sun-light,  so  that  exposure  to  it  brings  on  the  symp- 
toms of  hay  fever;   in  another,  a  similar  idiosyncrasy 
as  to  dust— the  most  common  of  all  the  excitants  of 
this  disease;  in  another,  against  fresh  hay;  in  another, 
against  ipecac  or  other  drugs;  in  another,  against  old 
hay;  in  another,  against  the  odor  of  roses,  or  other 
flowers;  in  another,  against  the  pollen  of  corn,  or  of 
some  of  the  grasses,  or  of  certain  weeds,  as  Roman 
wormwood,  or  golden  rod;  in  another,  against  some 
of  tlie  common   fruits — as  grapes,   apples,   pears  or 
peaches,  or  straw beries,  or  raspbenies,  or  watermelons; 
and  so  on    infinitely — new  developments    appearing 
every  year.     On  this  theory  I  based  the  nei*ve  treat- 
ment of  hay  fever,  and  predicted  that  by  electricity, 
strychnine,   belladonna,  camphor,  arsenic,  zinc,  and 
other  sedative  and  tonic  remedies,  we  sliould  be  able 
to  greatly  relieve  and  break  up  the  attacks  of  this  dis- 
tresshig  disorder.     For  several  years  this   prediction 
has  been  fulfilled,  not  only  in  my  own  practice,  but 
also  in  that  of  other  physicians. 

Another  idiosyncrasy  developed  by  nei'vous  exhaus- 
tion is  sensitiveness  to  cold  or  hot  water.  A  patient 
of  mine  could  never  bear  to  even  dip  his  hands  in 
hot  water,  so  disagreeable  were  the  sensations  it  pro- 
duced; the  same  patient  was  abnormally  ticklish  and 
timid. 

Dr.  Harris,  in  a  recent  aiiiclo  on  functional  nervous 


92  NERVOUS  EXHAUSTION. 

troubles/  relates  a  case  of  a  man  of  middle  life,  who, 
on  getting  up  in  the  morning,  would  feel  entirely- 
well;  but  as  soon  as  he  had  washed  and  wiped  his 
hands  they  would  begin  to  bum,  tingle,  and  ache  very- 
much,  as  when  brought  near  the  fire  after  ex]3osure  to 
snow.  After  a  few  seconds,  they  svould  begin  to  swell, 
and  would  continue  to  swell  for  five  or  ten  minutes  to 
such  a  degree  that  he  could  not  close  or  use  them.  In 
the  course  of  an  bour  or  more  the  swelling  would  go 
down,  but  would  recur  whenever  he  rubbed  his  hands. 
The  phenomena  disappeared  in  a  week  without  treat- 
ment. 

Sensitiveness  to  Changes  in  the  Weather  is  a  very 
often  observed  symptom  of  nervous  debility;  depres- 
sion of  the  nerves  makes  the  body  a  good  barometer. 
For  twentj^-four  houi-s  and  more  before  a  storm  comes 
on,  the  acliing  and  worn  nerves  foretell  in  every  part 
of  the  physical  organism  what  is  coming.  The  sky 
may  be  clear,  but  the  spirits  are  cloudy.  The  tender- 
ness of  bunions  and  coins,  the  acliing  and  stiffness  of 
rheumatic  and  neuralgic  sufferers,  the  general  gloomi- 
ness and  misery  of  the  exhausted  before  and  during 
bad  weather  are  not  imaginations,  but  reahties  as  truly 
as  small  pox  or  the  measles,  and  quite  as  much  worthy 
of  professional  study  and  consideration. 

In  the  Inebriate  Asylum  of  Kings  County,  it  has 
been  proved,  by  the  obseiwatious  of  the  Superintend- 
ent, Mr.  "Willett,  that  the  patients  become  worse  as  the 
mercury  in  the  barometer  goes  down;  their  desire  for 
stimulants  comes  upon  them  with  special  force  when 
there  is  diminished  atmospheric  pressure. 

'  St.  Louis  Medical  and  Surgical  Journal,  April,  1878.  Dr. 
Harris  assumes  that  many  of  the  cases  that  he  relates  are  of  ex- 
clusively malarial  origin,  and  that  such  symptoms  are  only  seen 
in  malarial  regions.    In  this  supposition  he  is  quite  in  error, 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  93 

Patients  of  this  class  are  oftentimes  made  profoundly 
worse  by  the  depressing  atmosphere  of  dog-days,  and 
generally  by  the  extreme  heat  of  our  summers.  The 
latter  half  of  August  is  especially  severe  on  these 
cases.  Neurasthenics  are  painfully  sensitive  to  both 
heat  and  cold — mid-smnmer  and  mid- winter  distress 
them  about  equally;  they  are  very  easily  chilled  by 
weather  even  the  reverse  of  cold.  They  are  very  sen- 
sitive to  exposure  to  cold,  or  over-exertion  of  any  kind. 
Getting  over-fatigued  has,  for  a  large  number,  the 
same  effect  as  being  exposed  to  cold.  Not  only  does 
the  heat  of  mid -summer  bear  heavily  on  their  re- 
sources, but  they  suffer  positive  and  severe  pain  from 
simple  heat,  even  when  they  are  not  exercising.  In 
short,  their  margin  for  bearing  the  extremes  of  tem- 
perature is  a  very  narrow  one.  In  whiter  they  must 
dress  more  heavily,  in  summer  more  hghtly  than 
others. 

A  person  nei'vously  exhausted  is  far  more  likely  to 
be  prostrated  during  the  extreme  heat  of  our  summer; 
and  when  once  prostrated,  all  his  symptoms  are  made 
worse;  indeed,  imnstroke  may,  and  very  often  does, 
bring  on  many  symptoms  of  neurasthenia  in  a  person 
previously  well. 

Localized  Peripheral  Numbness  and  Ilypercesthe- 
sia. — In  any  portion  of  the  peiiphery  — the  face,  tlie 
arms,  the  ends  of  the  fingers,  the  thighs,  the  legs,  and 
the  toes — there  may  be,  in  nervously  exhausted 
patients,  persistent  numbness  of  a  definitely  localized 
character,  or  excessive  sensibility,  similarly  localized. 
In  some  cases,  this  local  periplieral  hypenpsthesia 
amounts  to  a  very  distressing  disease.  I  was  once 
consulted  by  a  physician  who  had  hypera3sthesia  of 
the  left  hand,  caused  api)aiently  by  local  injury  acting 
on  a  nervous  diathesis.     The  condition  was  very  obsti- 


94  NERVOUS   EXHAUSTION. 

nate,  and  caused  much  distress.  I  once  had  under  my 
care  a  lawyer  who  had  a  burning  f  eehng  in  the  thumb 
and  fingers  of  the  right  hand,  with  pain  sometimes 
running  up  the  arm.  At  first  I  suspected  that  the 
symptoms  wei'e  premonitory  of  writer's  cramp.  The 
patient  went  to  Europe  and  took  various  treatments 
under  the  direction  of  Charcot  and  other  neurologists 
without  important  benefit;  but  is  now  able  to  pursue 
the  routine  of  his  profession.  I  have  now  under  my 
care  a  gentleman  who  has  had,  for  a  long  time,  a  sen- 
sation of  numbness  and  burning  at  the  ends  of  his 
thumbs,  at  the  bottom  of  the  heel,  and  around  the  legs 
and  ankles.  These  symptoms  are  accompanied  by  the 
usual  symptoms  of  cerebral  exhaustion  and  congestion 
— pain  in  the  head,  a  feeling  of  fullness  and  pressure, 
and  mental  dej^ression.  Sometimes  there  are  flying, 
Gtinging,  pricking  sensations  in  the  feet  and  legs,  that 
caused  one  European  physician  to  make  the  diagnosis 
of  "  flying  gout."  With  hygiene  and  electrical  treat- 
ment, this  patient  has  improved  in  a  manner  most 
encouraging;  and,  what  is  of  chief  inteiest  just  here, 
the  improvement  in  the  peripheral  symptoms  has  ex- 
actly kept  pace  with  the  improvement  in  the  brain 
symptoms,  showing  their  common  uature. 

Sjmiptoms  of  this  kind  excite  fear  and  dread — often- 
times as  indicating  gi*ave  and  structural  brain  disease, 
or  as  premonitory  of  apoplexy  ;  but,  in  the  majority 
of  cases,  they  are  the  results  and  signs  of  functional, 
not  stiiictural  trouble,  and  occur  in  people  who  live  to 
old  age. 

I  have  seen  a  number  of  cases  where  there  was 
numbness  on  a  limited  area  of  the  thigh,  and  all  have 
recovered  or  permanently  improved  without  a  very 
bad  history. 

Among  other  special  symptoms  coming  under  this 


SYMPTOMS  OP  NERVOUS  EXHAUSTION.  95 

head,  I  may  mention  a  sensation  as  though  a  pin  or 
many  pins  were  just  touched  to  the  skin  ;  a  tendency 
for  the  legs  and  arms  to  '*go  to  sleep,"  under  far 
slighter  pressure  than  in  the  normal  state  of  health, 
is  observed  in  cases  of  this  class.  Sitting  a  veiy  short 
time  in  a  hard  chair,  riding  in  an  omnibus,  or  car,  or 
carriage,  may  cause  the  foot  to  get  asleep,  when,  in 
entire  health,  no  sach  effect  would  have  been  produced 
by  the  same  cause. 

I  have  now  under  my  treatment  a  man  who  often 
wakes  up  at  night  with  a  strong  but  transient  sensa- 
tion of  numbness,  confined  to  the  track  of  the  ulnar 
nerve,  in  the  little  finger  and  inner  side  of  the  third 
finger.  In  other  cases,  other  nerves  of  the  arm  may 
be  involved,  and  all  the  fingers  may  be  numb.  Numb- 
ness of  this  kind  usually  goes  away  after  a  httle  shak- 
ing and  rubbing.  It  is  more  likely  to  come  on  at  night 
from  lying  on  the  arm  ;  but  in  the  daytime,  also,  it 
may  occur  when  the  arm  rests  for  a  few  moments 
over  the  back  of  a  chair.  When  one  is  specially  ex- 
hausted or  worried  from  any  cause,  this  transient  and 
local  numbness  is  more  likely  to  show  itself.  The 
pathology  of  this  state  is  probably,  if  not  certainly,  an 
obstruction  in  the  passage  of  the  nerve  force  througli 
mechanical  pressure.  In  the  highest  health,  sufficient 
pressure  will  i)roducc  this  condition,  and  if  the  pres- 
sure be  kept  up,  permanent  paralysis  may  occur  ;  but 
in  nervous  exhaustion,  when  the  nerve  force  moves 
slowly  and  with  very  little  vis  a  terijo^  much  slighter 
pressure  saffices  to  obstmct  its  passage — just  as  water, 
flowing  slowly  tliiough  a  rubber  tube,  can  bo  checked 
by  a  gentle  touch  of  the  finger,  but  if  flowing  rapidly 
and  with  force,  needs  firm  pressure  or  a  stop-cock. 

^l  Feeling  of  Profound  E.vhdustion  UnaccomjHvnled 
by  Positive  Pain.  — Attacks  of  a  sensation  of  absolute 


06  NERVOUS   EXHAUSTION. 

exhaustion,  as  though  the  body  had  not  strength  to 
hold  together,  comes  on  very  often  in  the  nervously 
exhausted.  This  feeling  of  exhaustion,  though  not 
exactly  pain  in  the  usual  sense  of  the  word,  is  yet,  in 
many  cases,  far  worse  than  pain.  These  attacks  may 
come  on  suddenly  without  warning,  and  may  suddenly 
disappear.  In  the  morning  one  may  be  able,  or  feel 
able,  to  run  on  a  wager  ;  in  the  afternoon  of  the  same 
day,  sitting  quietly  in  a  chair  seems  to  be  an  exhaust- 
ing effort  to  which  every  nerve  and  bone  and  muscle 
is  unequal.  The  gomg-to-die  feeUng  is  quite  common 
in  these  cases,  and  at  first  causes  alarm.  It  may  be 
experienced  either  in  the  day  or  at  night,  on  going  to 
sleep,  or  awaking  from  sleep.  This  symptom,  like 
many  of  these  symptoms,  appeai-s  at  puberty  and  at 
the  change  of  life ;  it  indicates  that  the  system  is 
straining  under  the  burden  placed  upon  it. 

Neurasthenic  patients  cannot  depend  upon  them- 
selves. One  day  they  can  do  with  impunity  what  on 
the  following  day  brings  about  distressing  results. 
At  one  time  they  may  be  able  to  work  hard,  take  long 
walks,  and  use  the  brain  severely — but,  under  the  same 
circumstances,  in  a  few  days  they  find  themselves 
unequal  to  anything  of  the  kind.  One  may  go  on  for 
a  long  time  almost  reckless  in  diet,  when  suddenly  an 
ordinary  article  of  food  causes  distress.  When  plan- 
ning to  go  upon  a  journey  or  to  undertake  any  respon- 
sibility of  any  kind,  they  cannot  tell  a  day  beforehand 
whether  they  wiU  be  equal  to  it — their  strength  is 
liable  to  drop  away  from  them  at  any  time  when  it  is 
needed. 

Unwonted  and  unaccustomed  muscular  exercise  is 
especially  irksome  to  neurasthenic  sufferers.  They  can 
do  very  well  in  an  ordinary  routine,  but  stepping  out  of 
this  routine,  and  attempting  something  new  to  them, 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  97 

they  quickly  become  wearied.  The  very  naiTOw  mar- 
gin of  muscular  force  is  soon  exhausted.  This  applies 
to  both  nervous  and  muscular  exertion. 

Ticklishness. — Nearly  all  persons  are  susceptible  to 
the  form  of  irritation  that  we  call  tickhng;  but  in 
nervous  exhaustion  this  susceptibility  may  become  a 
severe  annoyance.  A  gentleman  once  under  my  treat- 
ment for  many  of  the  symptoms  described  in  this 
paper— spinal  irritation  being  prominent — was  so  tick- 
lish on  the  breast,  stomach,  and  abdomen,  that  it  was 
very  difficult — indeed,  quite  impossible — to  apply  elec- 
tricity to  those  parts  with  any  satisfaction. 

Vague  Pains  and  Flying  Neuralgias. — The  so-called 
"  gi'owing  pains  "  in  the  young  are  of  this  class;  the 
force  in  the  system  is  insufficient  to  maintain  growth 
without  suffering  a  degree  of  impoverishment  which 
expresses  itself  by  a  subdued  growl  of  pain. 

Waving,  beating,  rolling  sensations  are  often  felt  by 
the  neurasthenic,  even  when  not  exactly  hysterical. 
Shooting  neuralgic  pains  in  the  limbs,  or  nearly  all 
parts  of  the  body,  cause  much  suffering  with  this  class 
of  patients. 

General  or  Local  Itching  {Pruritus). — Itching  occur- 
ring without  any  visible  change  in  the  appearance  of 
the  skin,  is  a  common  experience;  but  is  not  regarded 
as  pathological,  unless  it  be  quite  severe  and  persistent. 
In  certain  nervous  states,  it  becomes  an  element  of 
positive  distress.  Itching  of  tlie  scalp  sometimes  im- 
mediately follows  any  prolonged  and  exhausting  intel- 
lectual exertion.  I  know  a  man  who  was  once  troubled 
with  a  general  prickly  feeling  all  over  the  body,  and 
was  sufficiently  annoyed  tliereby  to  take  treatment  for 
it.  Certain  regions  of  the  face,  arms,  and  legs  may 
be  the  local  seats  of  itching,  whicli  varies  with  the 

general   condition  of    the  nervous  system.     A  lady 

7 


98  NERVOUS  EXHAUSTION. 

patient  of  mine,  of  neurotic  inheritance  and  tempera- 
ment, was  liable  to  terrible  attacks  of  itching  on  a 
hmited  region  of  the  arm;  which  attacks  followed 
quickly,  almost  instantly,  after  nervous  disturbance, 
and  were  not  accompanied  by  the  appearance  of 
prurigo. 

In  the  arm  pits  there  is  sometimes  severe  itching  in 
neurasthenia.  I  have  lately  had  under  my  care  a  case 
of  long-standing  neurasthenia,  in  which  itching  in 
the  left  axilla  was  one  of  the  most  harassing  of  all  the 
symptoms.  The  symptom  quickly  yielded  to  large 
doses  of  sodium  bromide,  without  any  local  appHca- 
tions. 

General  and  Local  Chills  and  Flashes  of  Heat, — 
Disturbance  Of  circulation  both  follows  and  accom- 
panies disturbance  of  innervation.  Creeping  chills  up 
and  down  the  spine  are  common-place;  but  there  are 
symptoms  allied  to  this  not  so  familiar.  Thus  Dr.  J. 
H.  Sterling  had  under  his  treatment,  at  one  time,  a 
lady  whose  knees  were  Hterally  as  cold  as  ice— that  is, 
they  felt  to  her  as  cold  as  though  they  were  packed  in 
ice.  I  knew  of  a  case  where  there  were  limited  and 
small  areas  of  heat  and  cold  sensations  on  the  arms, 
I  have  also  known  cases  where  the  ankles  were  cold, 
even  when  other  j^arts  of  the  body  were  comfortable. 
After  fatigue  or  worry,  the  ears,  or  one  ear,  and  one 
foot  or  both  feet,  and  one  hand  or  both  hands,  may  be 
cold  to  the  touch— even  in  warm  weather,  and  in  a  hot 
room,  or  when  thickly  wrapped  up.  Patients  in  this 
state  are,  indeed,  like  Harry  Gill,  very,  very  cold,  no 
matter  what  they  put  on;  the  skin  may  be  almost  bHs- 
tered,  as  they  stand  near  the  fire,  and  yet  chills  are 
running  all  over  them. 

Long  writing,  which  may  produce  symptoms  of 
writer's  cramp  in  others,  may,  in  the  nervously  ex- 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  99 

hausted  person,  cause  coldness  of  the  fingers,  hand,  or 
arm,  especially  when  the  arm  is  elevated.  Yet  more 
minutely  may  this  symptom  of  coldness  be  localized; 
spots  as  small  as  the  point  of  a  pin  apparently — espec- 
ially on  the  face — may  be  pinchingly  or  stingingly 
cold — this  sensation  quickly  appearing  and  quickly 
disappearing. 

Cold  Feet  and  Hands  are  symptoms  that  the  neu- 
rasthenic complain  of  in  at  least  half  the  cases. 

Nervous  Chills. — Attacks  of  chills,  in  many  respects 
resembling  chills  and  fever,  especially  the  dumb  ague, 
are  often  experienced  by  a  certain  class  of  neurasthenic 
sufferers. 

A  clergyman,  under  my  care  during  the  past  year, 
was  attacked  in  tliis  way,  and,  when  I  last  saw  him, 
could  not  tell  whether  the  symptoms  were  malarial  or 
simply  neurasthenic. 

My  friend  Dr.  Lente  tells  me  tliat,  in  cases  of  this 
kind,  he  has  only  been  able  to  make  the  diagnosis  by 
the  use  of  the  thermometer,  which  in  the  cases  of  neu- 
rasthenic cliills  indicated  a  different  temperature  from 
that  of  malarial  chills. 

Sudden  Givimj  Way  of  Gener(d  or  Special  Func- 
tions.— The  treacherousness  of  nervous  exhaustion  is 
one  of  its  most  constant  characteristics;  its  symptoms 
lurk  in  ambush  and  burst  upon  us  when  least  looked 
for,  when  we  fancy  oui'selves  utterly  and  forever  de- 
livered from  their  presence.  Tlio  neurasthenic  patient 
cannot,  therefore,  trust  himself  a  half-hour  or  even  a 
moment  in  advance.  In  the  morning  he  may  be,  or 
feel,  able  to  walk  five  miles;  in  the  afternoon,  from 
no  traceable  cause,  it  may  be  a  task  to  cross  the  street. 
Even  in  the  midst  of  any  labor — mental  or  muscular — 
his  strength  gives  out  as  suddenly  as  if  he  were  struck 
by  lightning.     I  knew  a  man  prostrated  for  two  yeai-s 


100  NERVOUS  EXHAUSTION. 

with  profound  neurasthenia,  who,  if  he  rose  and  crossed 
the  room,  might  become  absolutely  aphonic.  Two 
ladies  have  been  under  my  care  who  could  walk  readily 
for  perhaps  a  block  or  more,  when  instantly,  and  with- 
out warning,  their  limbs  would  give  way  beneath  them. 

Temporary  Paralysis. — Temporary  functional  paral- 
ysis of  certain  muscles  on  arm  or  leg,  or  of  the  muscles 
of  the  larynx,  are  sometimes  noticed  in  cases  of  neu- 
rasthenia. 

In  one  of  my  cases,  paralysis  of  an  arm,  lasting  bat 
a  short  time,  was  the  first  noteworthy  phenomenon  of 
the  disease. 

There  is  no  evidence  that  paralysis  of  this  kinc 
depends  on  any  stiiictural  disturbance  of  the  nerve- 
centres. 

These  temporary  paralyses  sometimes  recover  very 
suddenly  and  unexpectedly. 

Diseases  of  Men  (Involuntary  emissions,  partial  or 
complete  impotence,  irritability  of  the  prostatic  ure- 
thra).— Occasional  seminal  emissions  in  the  healthy 
and  unmarried  are  physiological — that  is,  they  are  not 
symptoms  of  disease.  Such  involuntary  discharges, 
when  excessively  frequent,  may  be  both  results  and 
causes  of  disease,  indicating  an  abnormal,  usually  an 
exhausted  state  of  the  nervous  system,  and  in  turn 
reacting  on  the  nervous  system,  increasing  the  very 
exhaustion  that  causes  it.  Such,  in  general,  is  the 
philosophy  of  all,  or  nearly  all,  cases  of  frequent  in- 
voluntary seminal  emissions. 

An  attack  of  acute  disease  of  any  kind  may  leave 
the  system,  during  convalescence,  in  a  state  where 
seminal  discharges  may  take  place  with  far  greater 
than  the  normal  frequency;  on  return  to  health,  this 
symptom,  with  all  other  symptoms  of  debility,  disap- 
pears. 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  101 

Chronic  neurasthenia  is  often  accompanied,  as  one 
of  its  symptoms,  by  seminal  emissions  or  other  evi- 
dences of  irritability  of  the  prostatic  urethra,  even  in 
those  who  are  married;  indeed,  some  of  the  most  per- 
sistent cases  I  have  ever  seen  have  been  in  married 
men.  In  almost  all  cases  of  long-standing  nervous 
exhaustion,  the  reproductive  system  necessarily  par- 
ticipates, sooner  or  later,  either  as  a  cause  or  effect,  or 
as  both.  In  very  many  cases,  local  disease  consequent 
on  abuse  of  these  parts  is  a  prominent  exciting  cause 
of  general  nervousness. 

Impotence — partial  or  absolute — when  it  appears  as 
an  effect  of  neurasthenia,  as  it  frequently  does,  usually 
recovers  with  the  improvement  in  the  nerves,  some- 
times without  special  treatment,  and  in  almost  all 
cases  is  reUeved  by  proper  treatment  faithfully  carried 
out.  It  is,  indeed,  more  relievable  than  many  other 
forms  of  genital  disorder. 

The  relation  of  the  male  genital  function  to  the  nerv- 
ous system  is  a  subject  of  the  highest  interest,  and  of 
great  complexity.  It  is  a  department  of  medical  in- 
vestigation that  has  been  for  too  long  neglected.^ 

Diseases  of  Women. — The  diseases  belonging  to 
woman,  as  woman,  may  be  either  the  causes  or  effects 
of  neurasthenia. 

It  lias  been  the  custom  to  regard  the  various  nervous 
symptoms  witli  wliich  women  suffer,  as  the  results  of 
any  uterine  disease  witii  wliicli  tliey  may  have  been 
afflicted;  but  the  wiser  gyna3cologists  of  the  present 

'  I  may  be  here  alIowe<l  to  refer  to  a  series  of  papers  tliat  I  have 
])eon  publishing  (.Jan.  25th  to  Doc.  (>th,  1H79)  in  the  New  York 
Medical  Jicconl,  on  Nervous  J )ihiease8  connected  with  the  Male 
Genital  Function.  (These  i)apers  have  been  gathered  tct^rctlier 
and  revised,  and  are  now  issued  in  l>ook  form  under  the  title  of 
"Sexual  Neurasthenia"  by  the  publisher  of  this  volume— Ed.) 


102  NERVOUS  EXHAUSTION. 

are  aware  that,  with  women  as  with  men,  disease  of 
the  reproductive  organs  may  be  a  result  of  exhaustion. 

The  various  congestions  and  displacements  and  in- 
flammations, and  especially  uterine  and  ovarian  irrita- 
bility, may,  and  do,  come  from  mal-nutrition,  which 
mal-nutrition  is  a  result  and  part  of  general  mal- 
nutrition of  the  whole  system.  In'itability  of  these 
organs,  of  the  ovaries,  of  the  uterus,  is  sometimes 
analogous  to  the  condition  of  the  brain  which  we  call 
cerebral  irritation,  or  of  the  spine,  which  we  call 
spinal  irritation,  and  will  not  yield  to  purely  local 
treatment.  Cases  of  this  kind  are  sometimes  treated 
for  a  long  time  without  any  satisfaction,  simply  be 
cause  the  general  constitutional  treatment  is  neglected. 
Constitutional  treatment  alone,  if  judiciously  and 
faithfully  carried  out.  may  sometimes  cure  these  cases 
without  any  local  application,  or  with  but  little,  as  has 
been  lately  shown  by  one  of  our  prominent  gynaecolo- 
gists, Dr.  Goodell. 

Oxalates,  Urates,  Phosphates,  and  Spermatozoa  in 
the  Urine. — The  relation  of  oxalate  of  lime  to  various 
nervous  symptoms  was  long  ago  pointed  out  by  Gold- 
ing  Bird,  and  the  importance  of  examining  the  urine 
for  the  deposits  of  the  oxalates  was  strenuously  insisted 
on  by  him ;  but  the  true  relation  of  such  deposits  to 
the  nervous  system  seems  not  to  have  been  fully  un- 
derstood either  by  him  or  by  those  who  have  since 
written  on  the  subject. 

As  a  matter  of  routine  I  have,  for  years,  been  accus- 
tomed to  have  the  urine  of  my  neurasthenic  patients 
examined  by  experts,  aud  in  the  majority  of  cases  it 
is  found  that  the  oxalates,  and,  in  some  cases,  the 
urates,  are  in  great  excess.  Amorphous  urate  depos- 
its are  noticed,  also  uric  acid  crystals. 

The  term  "  oxaluria,"  so  often  applied  to  this  condi- 


SYMPTOl^rS   OF  NERVOUS   EXHAUSTION.  108 

tion,  is  quite  analogous  to  the  term  "  spinal  irritation," 
as  applied  to  tenderness  of  the  cord  Avith  accompany- 
ing symptoms,  so  often  observed  in  neurasthenia.  To 
the  employment  of  such  terms  there  can  be  no  objec- 
tion, provided  those  avIio  use  them  understand  that,  in 
scientific  strictness,  they  do  not  mean  disease  of  a  dis- 
tinct character,  but  only  results  and  expressions  of 
neurasthenia — mal-nutrition  of  the  nervous  system. 
Tlie  urine  of  the  neurasthenic  is  often,  if  not  usually, 
abnormally  acid;  and  spermatozoa  are  frequently 
found.  In  a  phil{)soi)hic  sense,  these  oxalates  and 
urates  in  excess,  and  the  acidity,  are,  like  spinal  irrita- 
tion, cerebral  irritation,  neurasthenia,  asthenopia,  and 
dyspepsia,  results,  effects — in  a  word,  symptoms — and 
if  the  cause  at  all  of  other  symptoms,  are  secondarily 
so. 

Tliere  is,  indeed,  a  special  phase  of  neurasthenia,  to 
which  the  term  sexual  neurasthenia  may  well  be 
applied.  Spermatorrhoea  is  itself  a  cause  of  neuras- 
thenia, 

(htpiiifj  and  Yawnimj. — As  evidences  of  temporary 
fatigue,  gaping  and  yawning  are  familiar  enough, 
even  thougli  their  physiology  may  be  obscure.  In 
organic  disease  of  the  brain,  also,  frequent  and  pro- 
longed gaping  has  been  noticed. 

In  one  case  of  glosso- labial  paralysis  that  I  saw  a 
number  of  years  ago,  this  symptom  of  gaping  was  so 
fri'qucnt,  an<l  the  act  so  prolongtid,  as  t(j  be  ludicrous. 

In  neurasthenia,  gaping,  yawning,  and  stretching 
may  npi)ear  like  the  other  symptoms  mentioned,  and 
like  them  also  the  attacks  come  and  go;  they  ai'e  quite 
apt  to  follow  over-exertion  or  excitement,  even  when 
there  luis  been  no  loss  of  sleep.  A  neurasthenio 
patient,  now  under  my  care,  tells  mo  that  after  long 
reatling  a  newsi)np<'r  in  the  morning  after  breakfast, 


104:  NERVOUS   EXHAUSTION. 

he  is  troubled  with  gaping,  though  no  other  evidence 
of  weariness  annoys  hira;  in  his  case  the  eyes  are 
asthenopic,  and  prolonged  use  of  them  sometimes 
brings  on  various  symptoms. 

Appearance  of  Youth. — Persons  afflicted  with  neu- 
rasthenia, very  often,  and,  I  think,  in  the  majority  of 
cases,  where  the  condition  is  long-standing,  look 
younger  than  their  years;  they  bear  the  weight  of 
time  more  easily  than  the  phlegmatic  and  the  strong; 
and  when  between,  say  thirty-five  and  forty-five,  will 
pass  for  five  or  ten  years  below  their  actual  age.  I 
have  reached  this  generalization  not  hastily,  but  after 
much  observation  and  reflection.  Constantly  I  find 
myself  astonished  when  a  new  patient,  whom  I  have 
never  before  seen,  tells  me  his  age,  I  observe  that 
those  who  have  had  a  long  battle  with  their  morbid 
feelings,  who  have  been  perhaps  disabled,  crippled, 
exiled  by  nervous  incapacity,  look  ten  years  younger 
than  their  vigorous  friends.  The  neurasthenic  are,  as 
a  rule,  less  wrinkled  and  worn;  they  have  less  fat  and 
muscle  that  furnish  the  materials  for  flabbiness  and 
coarseness  of  feature.  Their  skins  are  thinner  and 
softer,  and  show  the  blood  more  readily.  They  are 
also  less  likely  to  be  attacked  with  those  degenerative 
changes  in  the  blood-vessels  and  the  skin  that  are  the 
signs  and  results  of  age.  In  a  word,  they  look  young 
for  the  same  reason  that  they  live  long. 

There  is  a  still  wider  generalization  that  can  be  veri- 
fied— namely,  that  the  nervousness  that  attends  civili- 
zation is  everywhere  accompanied  by  this  appearance 
of  youth.  The  higher  classes  look  younger  than  their 
years,  the  lower  classes  look  older  than  their  years. 
Some  time  since,  when  I  was  connected  with  the  Nerv- 
ous Department  of  Demilt  Dispensary,  New  York,  I 
noticed  that  the  majority  of  the  patients  looked  from 


STMPTOMS  OF  NERVOUS  EXHAUSTION.  105 

five  to  ten  years  older  than  they  were.  This  was  true 
of  both  sexes,  and  in  nearly  all  forms  of  nervous  dis- 
ease. Those  between  twenty  and  thirty  appeared  to 
be  thirty- five  or  more,  and  only  repeated  questioning 
in  some  cases  would  convince  me  that  there  was  not 
either  ignorance  or  deception.  But  scarcely  any  of 
these  patients  were  neurasthenic,  for  in  that  class 
neurasthenic  and  allied  affections  are  very  rare. 

Rapid  Decay  and  Irregidarities  of  the  Teeth. — The 
rapid  decay  of  the  teeth  is  one  of  the  symptoms  of 
nervous  exhaustion.  Although  a  nervous  person  may 
have  an  excellent  set  of  teeth,  providing  they  are  well 
taken  care  of  and  properly  filled  every  time  a  cavity 
appears,  yet  early  decay  of  teeth  in  the  nervous  is  to 
be  ranked  as  one  of  the  results  of  an  impoverished 
state  of  the  nei-vous  system. 

That  prematiu'e  decay  of  teeth  is  a  result  of  civiliza- 
tion is  an  undeniable  fact;  and  in  those  whose  consti- 
tutions are  depleted  of  force  the  teeth  are  rarely  good, 
and  they  are  only  kept  in  fair  working  order  by  the 
great  skill  of  modern  dentistry.  Dentists  are  the 
barometei'S  of  civilization;  their  rise  and  in'osperity  is 
one  of  the  most  instructive  facts  in  modern  sociology. 
American  dentists  are  the  best  in  the  world,  because 
American  teeth  are  the  poorest  in  the  world. 

Among  all  classes  of  brain-working  in-door  living 
Americans  the  teeth  usually  Ixjgin  to  decay  before  the 
age  of  20;  and  it  is  quite  rare  to  find  a  nen^ously  ex- 
liausted  person,  however  careful  he  may  have  been 
with  his  teeth,  who  can  exhibit  a  really  sound  set  at 
the  age  of  35  or  40;  it  is  more  probable,  that,  if  he 
have  any  teeth  of  his  own  at  all,  very  many  of  them 
are  filled ;  perhaps  some  of  them  in  several  i)laces,  and 
their  endin-ance  will  depend  upon  the  skill  with  which 
the  filling  has  been  done. 


106  NERVOUS  EXHAUSTION. 

Irregularities  of  the  teeth,  which  are  the  result  of 
deficient  nutrition  of  the  jaw,  are  likewise  barometers 
of  the  nervous  constitution.  The  jaws  not  being 
properly  fed  or  nourished,  the  teeth  faU  out  of  hne. 

In  Indians  and  negroes  the  teeth  decay,  but  not  so 
early  nor  as  rapidly  as  in  the  civihzed  white.  Irregu- 
larities of  the  teeth  Ukewise,  according  to  Norman  W. 
Kingsley,  our  best  authority  on  that  subject,  are  rare 
in  uncivilized  people. 

Hemi- Neurasthenia. — I  have  discovered  that  neu- 
rasthenia sometimes  affects  one  part  of  the  body  more 
than  the  other;  to  this  difference  I  have  apphed  the 
term  hemi-neurasthenia.  Thus  there  may  be  a  special 
degree  of  pain  on  the  left  side  of  the  head,  the  eye  on 
the  same  side  may  be  weaker,  more  painful  on  over 
use,  more  severely  photophobic,  the  lid  may  di'op 
lower,  the  eye  not  open  so  fully  and  freely;  the  arm 
and  the  leg  on  the  same  side  may  be  much  weaker 
than  on  the  other  side;  Ukewise  there  may  be  a  dis- 
position to  tremor  in  both  of  the  extremities  and  the 
muscles  of  the  face  on  one  side.  The  noises  in  the 
ears,  which  I  have  described  as  one  of  the  symptoms 
of  nem^asthenia,  may  be  restricted  entirely  to  the  right 
or  the  left  side,  even  when  there  is  no  demonstrable 
disease  of  the  ears. 

Likewise  muscae  volitantes,  or  specks  before  the 
eyes,  may  be,  and  indeed  often  are,  confined  to  one 
eye,  or  are  very  much  more  marked  in  one  eye  than 
the  other.  The  symptom  of  sick  headache  is  as  a  rule 
far  more  common  on  the  left  than  on  the  right  side, 
although  it  may  appear  on  both  sides  in  the  same 
individual;  Ukewise  the  symptoms  of  chilliness,  of 
creeping,  crawhng,  of  muscular  spasms,  fibriUary  con- 
tractions, localized  heat  and  cold,  may  be  especially 
observed  on  one  or  the  other  side  of  the  body.     The 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  107 

pains  in  the  calf  of  the  leg  and  cramps  may  be  re- 
stricted to  the  right  or  the  left  side,  or  may  be  far 
more  decided  on  one  side  than  on  the  other.  One  leg 
or  one  foot,  or  one  arm  or  hand,  may  be  cold  for  sev- 
eral hours  or  days,  whUe  the  hmbs  on  the  other  side 
are  of  normal  temperature.  One  ear  may  be  red  and 
hot,  the  other  may  be  of  a  normal  color  and  tempera- 
ture. 

Hemi -anaesthesia  of  one  side  of  the  body  is  quite  a 
familiar  symptom,  especially  in  hysteria;  but  veiy 
many  other  phases  of  nei-vous  debiUty  may  be  likewise 
confined  to  one  side  of  the  body. 

Course  and  Caprice  of  Symptoms. — Sufferers  from 
neurasthenia  oftentime  wonder  and  complain  that  they 
liave  so  many  symptoms;  that  their  pain  and  distress 
attack  so  many  parts  and  organs;  but  when  we  re- 
member that  neiuasthenia,  once  in  the  constitution,  is 
liable  to  attack  any  one  or  all  the  organs  and  func- 
tions, the  wonder  becomes  rather  that  they  escape  so 
many  of  the  symptoms;  it  is  in  truth  one  of  the  mys- 
teries of  the  disease,  that  those  who  are  afflicted  in 
some  directions  are  well  in  others.  Thus  one  who  is 
comparatively  neurasthenic,  and  has  Ijeen  afflicted  for 
many  years,  may  not  suffer  at  all  in  the  eyes,  nor  in 
the  ears,  nor  i)erhaps  in  the  stomach;  all  the  symp- 
toms may  bo  concent i*atud  in  the  spine  and  the  lower 
extremities,  with  the  genital  organs  or  with  the  repro- 
ductive system,  or  there  may  be  attacks  of  severe 
mental  depression;  and  it  is  worthy  of  note  that  those 
organs  and  functions  that  are  not  attacked  with  neu- 
rasthenia, that  are  passed  by  in  the  storm  that  sweeps 
through  the  system,  are  as  strong  and  enduriug  as  in 
an  entirely  healthy  pereon.  One  may  have  gr«iat  men- 
tal depression  at  times,  or  at  all  times  may  have  neu- 
i-asthenic  asthenopia,  the  various  forms  of  morbid  fear, 


108  NERVOUS   EXHAUSTION. 

general  debnity  in  its  various  phases,  and  yet  be  capa- 
ble of  great  muscular  endurance;  able  to  walk  long 
distances,  or  of  working  energetically  in  the  fields; 
anothei  with  the  same  disease,  with  the  symptoms 
differently  proportioned  or  divided,  may  be  capable  of 
constant  mental  effort,  although  physical  exertion  of 
any  kind  is  wearying.  The  way  in  which  the  stomach 
escapes  is  exceedingly  interesting;  I  sometimes  won- 
der at  the  digestive  power  in  these  cases.  I  remember 
a  consultation  I  had  with  a  physician  in  regard  to 
himself.  We  took  dinner  together,  and  when  I  saw 
the  quantity  and  quality  of  food,  much  of  it  being  of 
an  indigestible  sort,  of  which  he  partook  with  the 
greatest  relish,  I  thought  that  I  would  be  willing, 
almost,  to  take  upon  myself  all  his  symptoms,  which 
were  numerous  and  of  long  standing,  and  of  a  crip- 
phng  nature,  for  the  sake  of  his  digestive  capacity. 

Another  symptom  which  is  very  capricious  in  these 
cases  is  that  of  sleep:  usually  the  neurasthenic  do  not 
sleep  as  well  as  the  strong;  in  many  cases  it  is  their 
most  painful  and  annoying  symptom,  but  the  excep- 
tions are  not  rare  in  which,  although  almost  all  the 
others  symi3toms  appear,  sleep  is  perfect;  soon  as  they 
touch  their  pillow  they  drop  into  sound  slumber,  with- 
out the  assistance  of  artificial  aids;  and  rarely  ever 
wake  up  until  full  morning,  and  those  who  are  thus 
fortunate  may  be  the  feeble  with  many  fears,  may 
have  the  symptoms  of  myelasthenia,  may  be  greatly 
depressed  mentally,  may  have  sweating  extremities, 
muscular  debility,  disturbances  of  the  organs  of  special 
sense,  such  as  specks  before  the  eyes,  deceptive  sounds 
and  tastes,  neurasthenic  voice,  and  all  the  various 
functional  disorders  of  the  genital  system. 

It  is  interesting  also  to  note  what  may  be  called  the 
evolution  of  the  symptoms  at  different  periods  of  the 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  109 

disease.  In  a  long  course  of  neurasthenia,  certain 
symptoms  arise,  reach  their  height  and  fall  away,  and 
are  forgotten,  hut  are  replaced  by  other  symptoms, 
which  may  and  may  not  be  of  a  graver  character. 
There  would  seem  to  be  a  sort  of  progress  through 
which  neurasthenia  advances  from  its  early  to  its  late 
stage,  such  change  on  the  average  may  be  stated  as 
follows: 

The  first  symptoms  occur  oftentimes  in  the  youth, 
before  or  after  puberty;  the  most  frequent  symptom 
at  that  stage  is  sick  headache;  then  cones  a  period  of 
nervous  disorders,  often  preceded  or  followed  by  geni- 
tal disturbances,  sometimes  by  hypochondria;  then, 
after  some  changes,  come  sleeplessness  and  signs  of 
cerebral  congestion,  attended,  it  may  be,  witli  asthen- 
opia and  other  disorders  of  the  nerves  of  the  special 
sense. 

One  may  be  dyspeptic  perhaps  for  years  before  the 
spinal  cord  is  in  any  way  disturbed.  Symptoms  of 
myelasthenia  as  here  described,  in  the  upper  and  lower 
/art  of  the  back  and  spine;  tenderness;  morbid  sensa- 
tions of  the  lower  limbs.  Shooting  pains  inay  not  ap- 
pear until  the  sufferer  has  for  years  been  passing 
througli  the  process  of  incubation,  in  tlie  different 
stages  of  dyspepsia,  cerebral  hyperemia,  seminal 
weakness,  masturbation,  and  so  forth. 

Symptoms  seem  sometimes  to  wear  themselves 
out,  and  the  patient  passes  entirely  out  of  them;  and 
they  may  not  reappear,  although  the  average  health 
of  the  patient  has  been,  on  the  whole,  declining  rather 
than  improving.  A  physician  who  consulted  me  for 
many  years'  standing  symptoms  of  neurasthenia,  gave 
a  perfect  history  of  the  disease;  but  when  I  asked  him 
if  he  was  subjected  to  mental  dei)ression,  he  replied: 
"  I  passed  through  all  that;  "  and  this  I  observe  often- 


110  NERVOUS  EXHAUSTION. 

times  of  neurasthenics  in  middle  life,  that  symptoms 
of  the  early  stages  of  the  disease,  such  as  mental  de- 
pression and  dyspepsia,  have  ceased  their  annoyances. 

The  sudden  and  unaccountable  appearance  of  new 
symptoms  is  an  interesting  fact,  and  one  which,  to 
those  who  do  not  understand  the  philosophy  of  the 
disease,  oftentimes  causes  great  alarm. 

Patients  do  not  comprehend  why  they  should  have 
a  certain  symptom,  such  as,  for  example,  local  itching, 
or  specks  before  the  eyes,  cerebral  fullness,  or  pain  in 
the  back,  or  shooting  pains  in  the  limbs,  or  coldness  of 
the  extremities;  and  because  they  have  not  had  them 
before,  they  wonder  that  they  should  have  them  now, 
forgetting  that  with  disease,  as  with  school  teaching, 
there  must  always  be  a  first  time.  The  true  philosophy 
of  the  disease  shows  us  that  there  is  no  especial  mys- 
tery in  all  this;  that  we  should  wonder  quite  as  much 
why  we  should  not  have  symptoms  as  that  we  should 
have  them. 

Time  of  Life  at  which  Neurasthenia  is  most  fre- 
quent . — Neurasthenia  seems  to  be  most  common  be- 
tween the  ages  of  fifteen  or  sixteen  and  forty-  five  or 
fifty.  It  is  found  in  those  under  fifteen,  and  those 
over  fifty;  especially  between  fifty  and  sixty;  but, 
comparatively  speaking,  it  is  rare  and  different  in  its 
character  at  extremes  of  life.  This  is  a  fact  of  observ- 
ation, without  regard  to  any  theories  on  the  subject; 
and  is  especially  interesting  as  suggestive  of  the  in- 
timate relation  between  this  condition  and  the  repro- 
ductive system.  Infants  and  children  have  convul- 
sions, cerebral  diseases,  spinal  complaints,  paralysis, 
chorea  and  anaemia,  but  very  rarely  neurasthenia,  as 
here  described;  the  aged  have  anaemia,  paralysis,  and 
decrepitude,  but  not  any  considerable  number  of  the 
symptoms  referred  to  neurasthenia.     In  the  exhaus- 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  Ill 

tion  of  old  age  there  may  be  great  debility,  but  it  is 
not  accompanied  vritli  the  symptoms  which  we  find  in 
neurasthenia,  which  occur  in  those  between  the  ages 
of  fifteen  or  sixteen  and  sixty. 

Frequency  of  these  Diseases. — In  estimating  the 
relative  frequency  of  diseases  of  this  kind,  statistics 
are  of  little  value.  We  can  judge  only  by  the  observ- 
ations of  physicians  who  are  familiar  with  these  mala- 
dies, and  who  are  accustomed  to  diagnosticate  and 
treat  them 

There  are  very  few  physicians  of  large  experience  in 
general  or  special  practice,  particularly  in  our  great 
cities,  who  have  not  seen  many  such  cases,  even  though 
they  made  no  effort  at  diagnosis  or  treatment. 

Erb  in  Heidelberg  tells  me  that  he  has  seen  several 
hundred  cases  of  neurasthenia  alone,  and  his  practice 
comes  from  all  parts  of  Europe,  and  especially  from 
Germany,  where  these  affections  are  far  less  common 
and  annoying  than  in  the  United  States.  Probably  no 
single  fact  illustrates  the  frequency  of  this  disease 
more  impressively  than  this,  that  at  all  times  while 
on  duty,  I  have  a  number  of  physicians,  who  are 
themselves  sufferers  in  this  way,  under  my  care. 
Many  of  these  medical  patients  have  been  afflicted  for 
years,  without  ever  reaching  the  true  diagnosis  of  the 
condition,  and  in  not  a  few  instances,  the  real  debility 
and  distress  are  heiglitened  and  intensified  by  fear  of 
impending  disablement.  Overworked  and  overworried 
physicians  are  quite  apt  to  develop  this  disease,  and 
for  reasons  elsewhere  stated  (Chap.  III.)  are  also  more 
likely  to  develop  at  the  same  time  hypochondria  or 
pathophobia.  At  least  one  of  every  ten  of  those  who 
consult  me  for  neurasthenia  are  physicians. 

The  above-detailed  symptoms  are  not  imaginary,  but 
real;  not  trifling,  but  serious;   although  m^t  usually  or 


112  NERVOUS   EXHAUSTION. 

immediately  dangerous.  In  strictness,  nothing  in  dis- 
ease can  be  imaginary.  If  I  bring  on  pain  by  worry- 
ing, by  dwelling  upon  myself,  that  pain  is  as  real  as 
though  it  were  brought  on  by  an  objective  influence. 
Many  of  these  symptoms  show  quite  a  different  signifi- 
cance from  what  the  patients  fear  in  regard  to  them ; 
but  they  are  none  the  less  a  real  amroyance,  and  in 
some  instances  of  a  distressing  and  crippling  nature, 
depriving  one  of  happiness  and  usefulness,  and  en- 
veloping all  the  future  in  gloom. 

When  a  person  with  an  irritable  heart  fears  organic 
heart  disease,  and  asks  for  an  examination,  the  discov- 
ery that  there  is  no  organic  disease  of  that  organ  does 
not  invalidate  the  fact  that  he  does  have  certain  symp- 
toms connected  with  the  heart,  even  though  they  are 
not  of  a  j)erilous  character. 

Not  a  few  of  these  symptoms  are  physiological — a 
part  of,  and  consistent  with,  health;  and  are  them- 
selves, in  a  certain  degree,  either  the  result  or  cause  of 
disease;  such  symptoms,  for  example,  as  perspiration, 
blushing,  weeping,  gaping,  or  yawning.  When  they 
occur  naturally  aiid  mildly,  and  are  not  associated 
with  distinct  morbid  j)henomena,  they  are  physiologi- 
cal, and  do  not  suggest  disease,  any  more  than  laugh- 
ing or  sleeping;  but  when  these  symi)toms  occur  with 
a  frequency  relatively  great  and  excessive,  out  of  pro- 
portion to  the  exciting  cause,  or  are  associated  .with 
other  significant  signs  of  nervous  disease,  they  are 
pathological,  and  are  to  be  considered  in  making  out 
our  diagnosis.  Laughing  and  crying,  for  example,  are 
physiological  processes,  but  in  attacks  of  hysteria  they 
are  almost  diagnostic.  It  is,  therefore,  scientifically 
and  practically  no  objection  to  any  of  these  symptoms 
that  they  may  be  physiological. 

Hoiv  such  Cases  are  usually  Diagnosticated. — Cases 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  113 

with  any  one,  or  many,  or  all  of  the  above-described 
symptoms  are  diagnosticated  and  treated  in  all  kinds 
of  ways.  The  most  frequent  diagnoses  are  hysteria 
or  hypochondriasis  or  anaemia.  Others,  who  give 
more  attention  to  the  nervous  system,  make  more 
special  forms  of  diagnosis,  such  as  spinal  irritation, 
cerebral  anaemia,  cerebral  hyperaemia,  or,  perchance, 
spinal  hyperaemia.  If  an  oculist  were  consulted  for 
any  s3"mptoms  connected  with  the  eyes,  the  patient 
would  have  been  told,  formerly,  that  there  was  noth- 
ing the  matter — that  there  was  nothing  to  be  done, 
miless  it  be  to  rest  the  eyes  a.  httle  while;  more  re- 
cently, however,  glasses  would  be  prescribed;  and  pos- 
sibly, also,  some  tonic  treatment.  In  the  way  of  ther- 
apeutics, such  persons  would  be  advised  to  do  nothing; 
to  go  to  their  work — to  take  several  years'  vacation  in 
Em-ope — to  go  to  some  famous  baths — to  take  strong 
purgatives — and  so  on,  according  to  the  physician 
consulted.  In  rare  instances,  the  sufferer  might 
consult  a  physician  who  should  understand  what  his 
disease  was,  practically,  although  having  no  name  for 
it,  and  should  advise  treatment,  on  the  whole,  adapted 
to  the  case.  That  it  is  possible  for  a  patient  suffering 
from  these  symptoms  to  obtain  such  opposite  and 
inconsistent  treatment  from  some  of  the  best  physi- 
cians must  prove  the  importance  of  restudying  the 
whole  subject,  even  to  those  who  do  not  accept  all  the 
philoso})hy  of  this  work. 

Patients  of  this  class  veiy  naturally,  therefore,  often 
become  "rounders,"  going  from  one  physician  to 
another,  testing  all  waters  and  baths  and  climates;  on 
the  part  of  some  of  their  friends  getting  too  little  sym- 
pathy, on  the  part  of  others,  too  much.  If  but  once 
a  full  diagnosis  be  made  in  one  of  these  cases,  and  the 
patient  can  be  made  to  know  authoritatively  that, 


114  NERVOUS  EXHAUSTION. 

although  he  is  really  suffering  and  in  need  of  treat- 
ment and  well-directed  hj^giene,  he  is  not  in  danger  of 
organic,  hopeless  disease,  he  becomes  oftentimes  a  new 
being. 

Multitude  of  the  Symptoms. — The  objection  which 
some  have  brought  and  more  will  bring  against  this 
picture  of  the  neurasthenic  state  is,  that  it  has  such  a 
multitude  of  shapes  and  phases.  We  would  not  com- 
plain if  other  studies  of  the  nervous  system  were  criti- 
cised in  the  same  way.  It  is  a  law  which  is  deduced 
from  all  knowledge  of  the  brain  and  spinal  cord,  and 
of  the  reflex  action  of  the  nervous  system  in  general, 
and  which  is  confirmed  and  established  by  our  own 
observation  of  the  diseases  of  this  part  of  the  body, 
that  central  troubles  affecting  large  tracts  of  the  nerv- 
ous system,  or  even  limited  tracts,  are  liable  to  have 
an  immense  array  of  symptoms,  and  to  be  very  capri- 
cious in  the  display  of  them.  The  symptoms  of  ataxy 
under  modern  observation  have  grown  until  they 
make  ahuost  a  volume.  Even  as  I  write,  I  receive  a 
fresh  pamphlet  from  Erb,  of  Heidelberg,  on  ataxy. 
Now  neurasthenia  affects  a  larger  portion  of  the  sys- 
tem than  ataxy  (with  the  difference  only  that  one 
disease  is  functional  and  the  other  structural);  and  it 
should,  therefore,  have  at  least  as  many  symptoms,  if 
not  more;  and  those  who  study  neurasthenia  as 
thoroughly  as  they  study  ataxy,  will  have  no  difficulty, 
in  the  course  of  time,  in  confirming  all  that  is  here 
stated  in  regard  to  it.  They  will  not  see  all  the 
symptoms  in  the  first  case,  for  some  of  these  phenom- 
ena are  rare;  but  in  time  they  will  see  all,  or  nearly 
all,  and  will  become  familiar  with  them. 

These  symptoms  of  nervous  exhaustion  are,  in  a 
measure,  antagonistic  to  each  other — and  nervous 
exhaustion  is  itself  antagonistic  to  many  other  diseases 


SYMPTOMS  OP  NERVOUS  EXHAUSTION.  115 

— especially  of  the  acute  and  inflammatory  sort.  Dis- 
eases prevent  disease;  diseases  cure  disease;  diseases 
are  antidotes  to  disease.  To  this  numerous  class  of 
sufferers  it  is,  then,  a  consolation  that  their  disease  is 
itself  medicine  and  hygiene.  Opium-eaters,  I  am  told, 
are  comparatively  exempt  from  malaria,  and  in  the 
East  pass  unharmed  through  the  epidemics  of  cholera. 
Likewise  alcohol  inebriates  do  not  usually  experience 
all  the  symptoms  of  nervous  exhaustion.  Alcohol 
seems  to  act  as  an  internal  couiter-irritation.  Ex- 
cesses of  any  kind  that  injure  us  in  one  way  may  save 
us  from  being  injured  in  other  ways. 

Correlation  of  Nervous  Symptoms. — It  would  seem 
that  there  may  be  a  scientific  basis  for  the  popular  belief 
that  diseases  relieve  and  cure  each  other;  that  symp- 
toms in  one  part  of  the  body  take  the  place  of  symp- 
toms in  another  part.  It  would  seem,  indeed,  that 
diseases  which  are  here  described  represent  a  certain 
amount  of  force  in  the  body  which,  if  our  knowledge 
of  physiological  chemistry  were  more  precise,  might 
be  measured  in  units;  and  this  force  can  be  strongly 
concentrated  in  one  part  of  the  brain  or  the  spine,  or 
be  scattered  in  different  i)ortions  of  the  periphery.  In 
this  way,  we  can  account  on  just  physiological  grounds 
for  the  appearance,  for  example,  of  pain  in  the  head, 
as  soon  as  pain  in  the  stomacli  leaves  us;  of  alterna- 
tion between  the  head  and  the  stomach,  or  pelvic  i)ain, 
for  the  substitution  of  visceral  for  cutaneous  disorder, 
and  vice  versa;  for  tlie  relief  and  cure  of  many  dis- 
orders by  an  attack  of  acute  disease,  such  as  hay-fever 
or  diarrlid'a;  for  tlie  revolution  worked  in  the  consti- 
tuti(3n  by  a  protracted  sickness;  for  the  exemption  in 
neuralgic  disease  from  so  many  inflannnatory  troubles; 
for  the  restriction  of  tlie  effects  of  disease  of  the  repro- 
ductive system,  in  many  cases,  to  the  parts  affected, 


116  NERVOUS  EXHAUSTION. 

and  iri  some  cases  for  its  diffusion  through  the  whole 
frame — and,  most  interesting  perhaps  of  all,  for  the 
reUef  obtained  by  counter  irritation,  through  blisters 
or  actual  cautery,  or  through  hydro-therapeutics,  or 
through  applications  for  electricity.  These  nervous 
symptoms,  indeed,  play  a  sort  of  game  of  battle-door 
in  the  body,  in  which  the  disagreeable  sensations  are 
driven  from  one  part  to  another. 

The  periodical  and  rhythmical  character  of  some 
of  these  symptoms  is  of  much  interest. 

"V^niiile  this  work  is  being  revised,  I  have  been  con- 
sulted by  a  clergyman  of  middle  life,  who,  with  many 
other  symptoms  of  neurasthenia,  is  troubled  with 
attacks  of  special  and  peculiar  depression,  lasting  for 
about  a  day,  more  or  less.  These  attacks  are  ushered 
in  usually  by  a  feeling  of  mental  exaltation;  then  come 
diplopia,  Avith  other  abnormal  phenomena  of  vision, 
and  so  on  through  quite  a  regular  series  of  nervous 
symptoms.  Prostration  from  heat  was  the  original 
cause  of  the  attacks,  which  are  now  brought  on  by 
any  mental  or  physical  exhausting  or  disturbing  influ- 
ence. I  once  had  under  treatment  a  young  man  who 
had  attacks  of  nervous  depression  every  day  about 
noon;  they  lasted  but  for  a  short  time,  but  were  as 
periodic  as  chills  and  fever — and  like  chills,  and  hke 
the  preceding  case,  passed  through  definite  stages. 

A  student  of  medicine,  now  under  my  care,  has  had 
attacks  of  profound  weakness  in  the  region  of  the 
sacrum  and  coccyx,  with  unpleasant  sensation  in  the 
head,  coming  on  at  eleven  o'clock  in  the  morning,  and 
lasting  for  but  a  short  time. 

In  these  cases  we  at  first  suspect  malaria;  but  neither 
the  histoiy  nor  the  results  of  treatment  in  some  of  my 
cases  of  rhythmical  symptoms  are  in  harmony  with 
the  theory  of  malarial  origin. 


SYMPTOMS  OF  NERVOUS  EXHAUSTION.  117 

Nervous  exhaustion,  with  many  or  all  of  these 
symptoms,  is  compatible  with  the  appearance  of  per- 
fect health. 

For  this  reason,  as  w^ell  as  on  account  of  the  shppery, 
fleeting,  and  vague  nature  of  their  symptoms,  patients 
of  this  class  get  but  trifling  sympathy.  Sometimes 
they  are  fat  and  hearty,  and  have  a  ruddy,  vigorous, 
strength  suggestive  appearance;  sometimes  also  they 
grow  fatter  as  they  grow  worse.  Noticeably  the  dis 
appearance  of  symptoms  in  the  stomach,  and  the  ap- 
pearance in  their  stead  of  symptoms  in  the  brain  and 
spinal  cord,  is  followed  by  increase  in  weight  that 
deceives  the  friends,  the  physician,  and  even  the 
patient  himself.  Thus  it  happens  that  patients  get  the 
least  sympathy  when  they  most  need  it. 

Four  years  since,  a  prominent  politician  consulted 
me  for  a  medley  of  nervous  symptoms  induced  by 
sunstroke — a  not  uncommon  cause  of  neurasthenia. 
He  was  an  enormous,  Herculean  man,  but  gave  a  his- 
toiy  that  would  well  have  befitted  the  most  delicate 
and  hysterical  woman. 

A  pliysician  who  once  called  upon  me  and  had  op- 
poriunity  to  see  a  number  of  other  cases  tiiat  came  on 
the  same  day,  remarked  witli  sui-prise,  "  Your  patients 
are  giants;  "  and  to  some  of  the  worst  cases  that  were 
under  my  care  tliis  statement  will  justly  a])ply. 

It  cannot  be  repeated  too  often  tliat  a  patient  may 
be  of  great  size  and  weight,  and  have  a  muscular  de- 
velopment both  large  and  hard,  capable  of  great  phy- 
sical endurance,  and  at  the  same  time  be  in  his  nervous 
system  as  weak  as  a  bed-ridden,  hysterical  girl. 


CHAPTER  III. 

THE  NATUEE   AND   DIAGNOSIS   OF  NERVOUS 
EXHAUSTION. 

The  importance  of  making  a  differential  diagnosis 
between  symptoms  of  neurasthenia,  as  detailed  in  the 
previous  chapter,  and  the  symptoms  of  organic  or 
structural  diseasg  of  the  brain  and  spinal  cord  and  per- 
ipheral nerves,  is  incalculable.  Very  many  of  the 
symptoms  of  functional  and  organic  disease  are  the 
same,  or  apparently  the  same,  and  there  is  an  easy 
liability  to  confound  them,  especially  when,  as  is  often 
the  case,  the  patient  or  the  doctor  is  disturbed  in  his 
judgment  by  severe  apprehensions.  To  make  such  a 
differential  diagnosis  is  sometimes  the  severest  test  to 
which  the  neurologist  can  be  brought,  and  one  of  the 
highest  value  for  the  happiness,  the  plans,  and  the 
whole  future  of  his  patient.  The  not  being  able  to 
meet  this  test  has  been,  and  is  now,  m  all  .countries  as 
well  as  our  own — particularly  in  the  last  twenty -five 
years — a  cause  of  frequent  errors  in  the  advice — both 
hygienic  and  medical — given  to  patients;  for  both  the 
prognosis  and  treatment  of  neurasthenia  is  oftentimes 
quite  the  opposite  of  the  prognosis  and  treatment  of 
incurable  cerebral,  spinal,  or  peripheral  nerve  lesions. 
If  we  were  compelled  to  be  guided  by  isolated  symp- 
toms, it  would  be  impossible,  in  many  mstances,  for 
human  skill  to  make  such  differential  diagnosis  be- 
tween neurasthenia  and  some  of  the  diseases  that  it 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  119 

simulates;  for  the  symptoms,  considered  by  them- 
selves, are  sometimes  precisely  the  same,  and  of  them- 
selves alone  would  not  point  towards  the  solution  of 
the  problem.  The  tendency  of  neuropathology  is  not 
toward,  but  away  from,  the  idea  of  single  patliogno- 
monic  symptoms.  It  is  by  considering  groups  of 
symptoms  in  their  relation  to  each  other,  and  to  the 
history  of  the  case,  that  we  make  out,  in  recent  times, 
the  diagnosis  of  ataxia,  or  of  any  of  the  different 
forms  of  spinal  disease,  or  of  hay  fever.  "V^Hienever 
any  of  the  diif erent  phases  of  professional  cramps  de- 
velop, such  as  of  musicians,  or  writers,  or  painters,  or 
telegi-aphers,  or  designers,  or  engi'avers,  or  artists,  or 
barbers,  or  counters  of  money,  there  are  single  symp- 
toms in  any  one  of  these  diseases  that,  in  themselves, 
might  mean  rlieumatism  or  neuralgia,  or  neuritis,  or 
diseases  of  the  joints  or  spine;  and  very  often,  indeed, 
this  mistake  in  diagnosis  is  made  in  spite  of  all  the  lit- 
erature and  teachings  upon  this  subject. 

A  number  of  times  I  have  been  consulted  by  medi- 
cal men  in  regard  to  themselves,  for  symptoms  which 
for  a  long  time  had  kept  tliem  in  a  state  of  alarm,  if 
not  despair,  lest  they  might  be  the  precursors  of  incur- 
al>le  disease  of  the  brain  or  spinal  cord;  and  after  an  in- 
terview I  have  had  tlie  pleasure  of  assuring  them,  in 
most  positive  language,  that  it  was  not  only  improba- 
ble, but  well-nigh  impossible  for  them  to  get  up,  if  they 
should  try,  any  organic  or  structural  disease  of  the 
nervous  system;  that  they  might  continue  in  their 
chosen  profession  as  long  as  they  sliouM  live — which 
might  be  and  probably  would  be  many  years — pro- 
vided only  they  could  carry  out  certain  lines  of  treat- 
ment. 

On  the  stage  road  between  Ticonderoga  and  Lake 
George,  travellers  are  pointed  out  a  natural  i)henom- 


120  NERVOUS  EXHAUSTION. 

enon  in  the  shape  of  a  double  tree,  the  two  divisions  of 
which  grow  up  side  by  side,  and  so  close  together  that 
they  apf>ear  as  one  trunks  until  at  some  distance  from 
the  ground  they  diverge,  one  into  a  maple  and  the 
other,  I  believe,  into  an  elm.  Just  so  functional  and 
organic  affections  may  have  at  the  outset  the  same 
symptoms,  and  for  a  time  may  run  along  together  side 
by  side,  perfectly  parallel,  and  to  an  ordinary  observer 
appear  absolutely  identical.  In  connection  with  this 
subject,  the  German  writers  have  especially  made  the 
mistake  of  assuming  and  of  teaching  that  the  causes 
of  functional  disease— such,  for  example,  as  sexual 
excess — are  also  hkewise  the  causes  of  organic  lesions 
such  as  are  found  in  ataxy  and  muscular  atrophy. 
These  errors  in  diagnoses  have  been  copied  by  authors 
in  other  countries  and  languages,  and  physicians  and 
medical  students,  on  reading  these  works  and  listening 
to  such  teaching  from  their  professors,  begin  most 
naturally  to  ask  themselves  whether  they  are  going  the 
road  that  leads  to  nervous  destruction;  and,  on  a  little 
reflection,  there  is  but  slight  difficulty  in  recalling  and 
conjuring  up  almost  any  number  of  symptoms  which, 
according  to  the  books,  ought  to  make  them  perma- 
nent and  hopeless  invalids,  if  not  send  them  to  a 
speedy  grave.  The  more  intelhgent  a  physician  is, 
and  the  more  thoroughly  he  keeps  up  with  the  litera- 
ture of  his  profession,  the  more  liable  is  he  to  fall  into 
this   annoying  and  alarming  mistake.^    One  of  the 

'  That  the  disease  may  last  many  years  there  is  no  doubt ;  that 
it  does  not  often  lead  to  organic  spinal  disease  is  equally  clear. 

On  this  subject  Erb  does  not  speak  so  positively.  He  says  :  "  I 
am  unable  to  state  whether  they  are  incurable  cases,  and  whether 
the  disease  may  last  a  great  many  years.  I  also  am  in  doubt 
whether  the  disease  can  pass  into  any  tangible  chronic  form  of 
spinal  disease  (myelitis,  sclerosis,  gray  degeneration.  .  .  Most 
patients  are  hypochondriacal  in  their  feelings;  and,  if  the  physi- 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  121 

best  physicians  I  know — a  man  of  large  experience 
and  of  general  culture  and  accomplishments — consulted 
me  a  number  of  years  ago  in  a  state  of  intense  depres- 
sion and  alarm,  on  account  of  spinal  exliaustion,  which, 
in  his  anxiety,  he  mistook  for  hopeless  spinal  disease. 
I  had  the  great  pleasure  of  comforting  him  with  the 
assurance  that  he  had  not  one  proof  of  structural  dis- 
order, and  that  by  a  coui-se  of  treatment  which  I  indi- 
cated to  him  he  could  substantially  recover.  The  pre- 
diction was  verified.  Since  that  time  I  have  several 
times  seen  this  gentleman,  or  have  heard  from  him, 
and  know  that  he  is  comparatively  well  and  engaged 
in  the  practice  of  his  profession.  An  experienced 
medical  gentleman  from  a  distant  city  once  came  to 
me  with  a  personal  history  of  neui*asthenia,  by  which 
he  had  been  kept  in  chronic  fear,  lest  it  might  be  nec- 
essary for  him  to  abandon  his  calling.  He  declared  that 
he  would  rather  die  than  become  a  hopelessly  paralyzed 
invahd;  and  yet  he  had  not  one  evidence  of  organic 
nerve  trouble,  although  his  condition  demanded  atten- 
tion and  treatment. 

A  physician  from  the  West — a  gentleman  of  un- 
usual intelligence — came  to  me  with  a  history  which, 
to  his  own  mind,  indicated  gi-ave  disease  of  the  eyes 
and  heart,  and  yet  all  the  best  ophthalmologists  agree 
that  the  eye  symptoms  indicated  only  functional  dis- 
order; a  like  conclusion  was  derived  from  examination 
of  the  heait  and  nen^ous  system. 

Not  long  ago  a  patient  consulted  me  for  brain  ex- 

cian  is  the  siilTcror,  he  is  apt  to  lot  his  mind  dwell  oa  this  antici- 
pation, and  to  bi'  made  wretched  by  the  thouf^ht." 

There  is  no  (juestion  that  the  majority  of  the  Ceases  of  ataxy,  re- 
ported as  cured  by  galvanization  by  Remak,  Meyer,  and  other 
f4ennan  writers  on  neurolofiry  and  electro-therapeutics,  wore  really 
ca8<^s  of  myelasthenia  (spinal  exhaustion)  or  simply  spinal  conges- 
tion. 


122  NERVOUS  EXHAUSTION. 

haustion  and  spine  exhaustion  combined;  with  many 
of  the  typical  symjDtoms  of  both  conditions.  About 
the  same  time  she  also  consulted  another  physician, 
who  made  the  diagnosis  of  rush  of  blood  to  the  head, 
and  predicted  apoplexy.  There  was  no  doubt  that  the 
patient  did  have  an  unbalanced  circulation,  and  at 
times  was  afflicted,  as  such  cases  often  are,  with  tem- 
porary congestions  of  the  brain  and  spine;  but  these 
congestions  were  not  the  disease,  any  more  than  the 
black  vomit  is  yellow  fever;  and  there  was  no  hkeh- 
hood  that  they  would  lead  to  apoplexy,  although  there 
was  just  ground  for  fear  that  her  condition  unrelieved 
might  in  time  lead  to  nervous  invalidism.  As  this 
work  is  passing  through  the  press,  I  am  consulted  by 
a  young  man  with  mild  symptoms  of  spinal  exhaustion, 
who  had  been  assured  by  his  last  adviser  that  he  had 
the  premonitory  symptoms  of  paralysis  of  the  lower 
limbs;  he  was  astonished,  incredulous,  when  I  informed 
him  that  he  was  in  no  more  danger  of  paralysis  than 
of  leprosy,^ 

The  differential  diagnosis  of  neurasthenia,  therefore, 
so  far  from  being  easy,  is  oftentimes  exceedingly  diffi- 
cult; and,  in  individual  cases,  it  may  be  absolutely  im- 
possible to  establish  a  diagnosis,  until  the  patient  has 
been  watched  and  closely  studied  for  some  time. 
There  are  stages  in  the  history  of  nervous  symptoms 
where  the  tide  may  turn  either  way,  towards  func- 
tional or  nervous  .disease;  and  which  way  it  shall  turn 
is  not  to  be  determined  by  a  single  glance.  In  order 
to  be  able  to  make  a  diagnosis  of  neurasthenia,  it  is 

'  Erb  remarks  on  this  point:  "Abundant  experience  has  shown 
nie  that  these  cases  are  not  rare,  and  are  of  great  practical  conse- 
quence. For  they  cause  much  anxiety,  not  only  to  the  patient, 
but  also  to  the  physician,  owing  to  the  striking  resemblance  they 
possess  to  the  first  stage  of  severe  disease  of  the  cord." 


DIAGNOSIS  OP  NERVOUS  EXHAUSTION.  123 

needful  that  we  should  know  thoroughly  all  the 
symptoms  of  organic  disease,  acute  and  chronic,  and 
of  the  different  compHcations  which  enter  into  the 
diagnosis;  such,  especially,  as  come  from  syphihs  and 
malaria.  He  who  knows  only  neurasthenia,  does  not 
know  even  that.  Tlie  symptoms  of  ataxy,  of  muscu- 
lar atrophy,  of  general  paralysis  of  the  insane,  of  cere- 
bral and  spinal  congestion,  and  all  the  different  forms 
of  professional  cramp,  such  as  that  of  writers,  musi- 
cians, artists,  and  the  like,  must  be  familiar,  both 
theoretically  and  practically,  to  one  who  is  to  be  pre- 
pared at  all  times  to  make  a  diagnosis  of  the  symptoms 
of  neurasthenia. 

Distinguished  from  Organic  or  Structural  Nervous 
Disease. — The  points  in  tlie  differential  diagnosis  of 
neurasthenia  from  the  organic  disease  which  it  simu- 
lates, and  with  which  it  is  so  often  confounded,  are  as 
follows: 

1.  The  symjytoms  of  organic  disease  are  usually  fixed 
and  stable,  while  very  many  of  those  of  neurasthenia 
and  allied  states  are  fleeting,  transient,  metastatic, 
and  recurrent.  Very  many  of  the  signs  of  neuras- 
thenia and  alUed  states  appear  in  organic  affections, 
and  in  Ijoth  conditions  they  are  precisely  the  same,  so 
that  of  themselves  alone  they  would  be  no  guide  in  the 
differential  diagnosis;  spinal  tenderness,  shooting  and 
stabbing  and  boring  neuralgias,  cardiac  ixilpitation, 
insonniia,  or  drowsiness,  failure  of  memory,  sexual  ex- 
liaustion  and  involuntary  emissions,  mental  depression, 
j)ain  and  heaviness  in  the  heafl  and  back,  disturbances 
of  the  nerves  of  special  sense,  hypenEsthesia  and  anaes- 
thesia, local  or  general,  coldness  of  the  extremities, 
twitchings  of  muscles— all  these  and  other  results  of 
the  functional  nervous  disorder  we  are  considering, 
manifest  themselves  in  spinal  congestion,  in  ataxy,  iu 


124  NERVOUS  EXHAUSTION. 

muscular  atrophy;  but  in  functional  troubles  they 
come  and  go,  and  change  about  and  alternate,  appear 
and  disappear  and  reappear  without  any  clear  cause, 
and  sometimes  utterly  vanish  even  without  treatment; 
in  the  nervously  exhausted  these  symptoms  fly  about 
from  one  part  or  organ  to  another,  as  from  the  head  to 
the  stomach  or  back,  from  the  upper  to  the  lower  part 
of  the  spine;  from  the  front  to  the  back  of  the  head; 
one  day  it  is  the  eyes  that  are  troubled;  another  day 
the  eyes  are  well  and  the  stomach  is  complaining,  as 
though  it  would  never  cease:  but,  in  a  few  hours  per- 
haps, the  digestion  seems  to  be  all  right,  and  the  head 
is  in  suffering,  and  so  through  the  whole  system. 
The  wonderful  precision  that  ophthalmology  has  at- 
tained enables  us  to  study  the  neurasthenic  symptoms 
of  the  eye,  negatively  at  least,  in  a  most  interesting 
way.  To  those  cases  of  weakness  of  the  eyes  with 
pain  on  reading  or  sewing,  where  all  the  tests  fail  to 
discover  any  objective  cause,  and  which  are  not  bene- 
fited by  glasses,  I  have  applied  the  term  neurasthenic 
asthenopia.  My  friend  Dr.  Eoosa  lately  called  my 
attention  to  the  fact  that,  in  testing  the  visual  power 
of  patients,  it  is  sometimes  observed  that  there  is  a 
momentary  capacity  for  perfect  sight  that  appears 
and  disappears.  These  vanishings  of  functional  power 
are  also  observed,  according  to  Dr.  Eoosa,  while  testing 
the  hearing.  After  an  organic  malady  once  gets  es- 
tablished, it  reveals  itself  by  a  group  of  symptoms 
that,  however  much  they  may  vary  in  intensity,  are 
mostly  fixed  and  constant. 

2.  There  are  certain^  though  not  luell  knoivn  or 
always  recognized  symptoms  of  neurasthenia  and 
allied  states  ivhich  do  not  often,  if  at  all,  appear  in 
structural  disorders. — Among  this  class  of  symptoms 
that  are  more  or  less  peculiar  to  functional  nervous 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  125 

disease  are  these:  general  or  local  itching  (without 
objective  cause),  tenderness  of  the  scalp,  teeth,  and 
gums,  flushing  and  fidgetiness,  markedly  tremulous 
pulse,  without  cardiac  disease,  sick  headache,  asthen- 
opia, flushing,  new  and  special  idiosyncrasies  in  regard 
to  food  and  medicine,  and  which  did  not  exist  i)rior 
to  the  illness,  ticklishness,  morbid  desire  for  stimulants 
and  narcotics,  hopelessness,  hypochrondria,  and  mor- 
bid fears.  If  some  of  these  symptoms  do  appear  in 
real,  organic  disease,  it  is  yet  rare  that  all,  or,  indeed, 
any  considerable  number  of  them,  would  appear  to- 
gether in  any  one  case:  some  symptoms,  as  sick  head- 
ache, for  example,  are  generally  inconsistent  with 
grave  structural  disease  of  the  nerve  centres;  when  the 
brain  or  spinal  cord  becomes  seriously  injured,  our 
sick  headaches  are  apt  to  leave  us.  Likewise,  the  lack 
of  desire  for  fluids  which  is  seen  in  neurasthenia  is  not, 
as  a  rule,  so  noticeable  a  symptom  in  structural  mala- 
dies. 

3.  In  organic  disease,  reflex  activity  is  generally 
diminished;  in  functional  disease,  reflex  activity  is 
generally  increased. — This  distinction  is  of  great  prac- 
tical service,  since  not  a  few  of  the  phenomena  referred 
to  in  neurasthenia  and  allied  states  are  either  excited  by 
reflex  action,  or  tend  to  excite  by  reflex  action  symptoms 
in  various  parts  of  the  body.  The  human  body  in  health 
is  a  bundle  of  reflex  actions;  every  organ,  when  dis- 
turbed or  iiTitated  in  any  way,  may  set  up  a  disturb- 
ance or  irritation  in  some  distant  part  or  organ;  but, 
when  the  system  is  in  a  c<jndition  of  neurasthenia,  this 
reflex  irrital)ility  is  often  exaggerated — indeed,  is 
usually  so;  and  in  case  of  hysteria,  the  sensitiveness  is 
sometimes  so  great  tliat  the  slightest  touch  on  any 
part  of  the  body,  or  even  the  gentlest  possible  psychical 
initation  or  excitement,  may  give  rise  to  violent  con- 


126  NERVOUS  EXHAUSTION. 

vulsions.  To  a  less  degree  than  in  pronounced  hysteria, 
this  exaltation  of  reflex  activity  is  observed  in  all 
types  and  phases  of  functional  nervous  disorder. 

When  any  part  or  point  of  the  body,  external  or  in- 
ternal, on  the  periphery,  or  at  the  centre,  is  irritated, 
some  other  part  is  liable  to  be  in  some  way  changed 
for  the  better  or  worse;  but  there  are  par  excellence 
three  great  centres  of  reflex  action — the  brain,  the 
stomach  and  digestive  apparatus  and  the  reproductive 
system.  When  any  one  of  these  three  reflex  centres 
is  irritated  by  over-use  or  direct  abuse,  the  injury  is 
likely  to  radiate  or  reverberate  in  any  or  in  all  direc- 
tions; we  cannot  tell  just  where,  any  more  than  we 
can  tell  where  lightning  will  strike.  In  this  way,  dis- 
ease may  be  excited  in  parts  quite  distant  from  the  seat 
of  irritation.  This  accounts,  in  part,  for  the  immense 
number  and  variety  of  symptoms  and  abnoi-mal  sensa- 
tions from  which  the  nervously  exhausted  suffer. 
Hence  it  is  that  it  is  so  difficult  to  tell  from  the  symp- 
tojiis,  or  the  locality  of  the  symptoms,  just  ivhere  the 
disease  or  the  source  of  the  disease  really  is.  If  a  man 
thinks  and  worries  too  much,  it  is  not  necessarily  the 
head  that  will  complain;  there  may  be  pain  in  the  calf 
of  the  leg,  or  in  the  eyes,  or  in  the  stomach  or  bowels, 
or  in  any  part  of  the  back;  possibly  the  arms  will 
ache,  or  the  fingers;  or  the  genital  organs  will  become 
cold.  Very  often  cold  feet  and  hands  are  the  first 
signs  of  mental  overwork.  Indigestion,  however  com- 
plicated, or  by  whatsoever  causes  produced,  may  affect 
every  part  of  the  body  except  the  stomach,  and  in 
ways  beyond  computation.  General  aching  of  the 
bones,  pains  in  the  calf  of  the  leg,  creeping  chills  on 
the  spine,  actual  pain  in  the  back  and  back  of  the 
head,  facial  neuralgia,  sick  headache,  roaring  in  the 
head,  flushing  of  the  face  and  eyes,  pain  in  the  vertex, 


DIAGNOSIS   OF  NERVOUS   EXHAUSTION.  127 

cardiac  palpitation,  diarrhoea:  these  are  some  of  the 
results  of  indigestion  in  nervous  constitutions;  and 
very  frequently  patients  chase  up  one  symptom  after 
another  until  they  get  wearied,  without  either  finding 
rehef  or  suspecting  the  tiTie  seat  of  the  disorder. 

Disorders  of  the  genital  ajjparatus  in  either  sex  are 
continually  exciting  disease  in  remote  organs,  and  it  is 
observed  that  in  women  mild  irritation — slight  and 
limited  disturbance — produces  severer  reflex  trouble 
than  coarse  and  grave  lesions;  superficial  disorder  of 
the  cervix,  for  example,  often  inducing  more  annoy- 
ing pains  and  distresses  in  the  head  than  incurable 
cancers;  and  in  men,  also,  but  a  little  prostatitis  or 
urethral  or  preputial  irritation,  not  only  phimosis,  but 
even  elongation  with  secretion  of  smegma,  are  con- 
stantly the  sole  and  demonstrable  origin  of  hypochon- 
driasis, dyspepsia,  and  other  nervous  symptoms.^     In 

'  Til  regard  to  the  relation  of  neurasthenia  to  the  genital  func- 
tion, and  to  disease  of  the  male  and  female  reproductive  organs, 
two  errors  have  prevailed  :  that  the  genital  organs  have  nothing 
to  do  with  the  causation  of  neurasthenia  and  allied  affections, 
and  that  they  are  the  exclusive  causes  of  such  affections. 

An  eminent  neurologist  once  remarked  to  me  that,  in  all  the 
cases  of  spinal  irritation  and  analogous  disorders  that  he  saw,  the 
uterus  was  primarily  at  fault  ;  on  the  otlier  hand,  an  eminent 
gynfecologist.  speaking  of  tlie  sjune  suliject,  observed  that  he  saw 
cases  of  neurasthenia  where  there  was  no  proof  of  any  depend- 
ence on  uterine  disease.  Tlie  gyiuecologist  was  right ;  for,  while 
many  cases  of  neurasthenia  do  take  their  origin  in  uterine  and 
ovarian  maladies,  there  are  also  many  that  have  nothing  to  do 
■with  the  reproductive  system  ;  they  are  as  likely  to  be  the  causes 
as  the  effects  of  uterine  disturbances.  This  was  substantially 
the  view  taken  by  Dr.  (umxIcII,  in  his  paper  on  neunusthenia,  at 
tiie  late  meeting  of  the  American  Gyn*cologi(!al  S<»'irty,  and  it 
was  not,  so  far  as  I  can  learn,  disputed  by  any  of  the  authorities 
In  gynaecology  who  listened  to  it.  Tli«-re  is,  in  fact,  a  manifest 
dispf)sition  among  gyii;i'c<>logists  to  revive,  in  a  certain  measure, 
the  coubtitutiouul  treatment  of  some  of  the  cases  that  come  under 


128  NERVOUS  EXHAUSTION. 

the  neurasthenic  one  never  can  tell  from  the  locality 
of  the  pain  or  other  symptom  where  the  disease  really 
is;  the  diagnosis,  to  be  thoroughly  satisfactory,  re- 
quires, in  some  cases,  an  examination,  so  far  as  practi- 
cable, into  the  condition  of  all  the  principal  organs  of 
the  body. 

Now,  while  in  certain  organic  affections — as,  for  ex- 
ample, spasmodic  spinal  paralysis  and  amyotrophic 
lateral  sclerosis — reflex  activity  of  a  certain  kind  may 
be  increased,  yet,  as  a  law,  the  reverse  appears.  The 
absence  of  the  tendon  reflex  in  the  majority  of  cases 
of  ataxy  is  an  extreme  illustration  of  the  tendency  of 
organic  disease  to  diminish  reflex  irritability. 

4.  Neurasthenia  and  allied  troubles  are  most  likely 
to  occur  in  those  in  luhom  the  nervous  diathesis  pre- 
dominates.— Among  the  chief  signs  of  the  nervous 
diathesis  are  fine,  soft  skin,  fine  hair,  deHcately-cut 
features,  and  tapering  extremities.  Those  who  ex- 
hibit these  characteristics  are  the  victims  of.  functional 
as  distinguished  from  organic  diseases  of  the  nervous 
system.  With  exceptions  both  ways,  this  general  law 
will  be  a  good  guide  in  establishing  a  diagnosis.^ 

their  care,  and  so  far  this  is  right.  Without  dispute,  also,  there 
are  some  cases  of  neui'asthenia,  as  of  hysteria  and  insanity,  that 
depend  entirely  on  genital  irritation,  and  would  nev^er  have  ex- 
isted but  for  such  irritation,  and  entirely  recover  with  the  removal 
of  the  irritation;  there  are  others  that  depend  in  j)art  on  irrita- 
tion from  this  source;  there  are  others  that  arise  entirely  inde- 
pendently of  all  irritation  of  that  kind.  There  is  no  doubt  that 
irritation,  congestion,  and  imprisonment  of  the  ovaries,  and  uter- 
ine displacements,  often  excite  neurasthenic  symptoms.  To  at- 
tempt, however,  to  explain  all  forms  and  phases  of  neurasthenia 
by  reference  to  the  reproductive  system  in  man  or  woman,  is  to 
study  neuro-pathology  in  a  partial,  fractional,  one-sided,  frag- 
mentary, imperfect  manner. 

'  For  more  extended  remarks  on  the  nervous  diathesis,  originally 
suggested  in  the  first  edition  of  Beard  and  Rockwell's  Medical  and 


DIAGNOSIS  Of  NERVOUS  EXHAUSTION.  129 

As  a  rule,  the  structural  diseases  are  found  in  the 
comparatively  strong — in  those  who  are  not  especially 
sensitive,  or  nervous,  or  delicate;  and  when  paralysis 
or  other  grave  symptom  appears  in  one  in  whom  the 
nervous  diathesis  strongly  predominates,  it  is  far  safer 
to  make  a  diagnosis  of  functional  and  temporary 
disease,  and  to  predict  in  time  entire  or  approximate 
reUef. 

Distinguished  from  Hypochondriasis  or  Pathopho- 
bia.— The  facts  in  regard  to  hypochondriasis  (or  path- 
ophobia) are  these:  First.  A  person  in  perfect  health, 
but  with  some  slight  symptoms,  may  through  igno- 
rance of  what  these  symptoms  mean,  be  led  intellec- 
tually to  suppose  that  he  has,  or  is  hable  to  get,  some 
grave  disease.  In  this  respect  he  simply  mistakes  in 
reasoning;  as  he  would  be  liable  to  mistakes  on  other 
subjects  in  which  he  is  a  non-expert. 

When  a  person  thus  situated  is  taught  by  a  person 
whose  judgment  he  respects  on  those  subjects,  his  fear 
all  ceases.  Such  persons  are  not  hypochondriacs  or 
pathophobics;  for,  as  soon  as  they  see  the  groundless- 
ness of  their  fear,  they  cease  to  fear. 

Secondly.  There  are  persons  who,  although  fully 
informed  on  the  real  significance  of  the  symptoms 
from  which  they  suffer,  or  suppose  they  suffer,  are 
none  the  less  alarmed  in  regard  to  it.  Instiiiction  does 
them  no  good,  but  oftentimes  makes  them  woi-se;  they 
are  under  the  influence  of  the  emotions — they  may 
perhaps  know  intellectually  that  there  is  no  reason  for 
their  fear;  but  their  emotions  control  them,  and  they 
go  on  fearing  just  like  those  suffeiing  from  other 
forms  of  morl)id  fear,  as  topophobia,  agorapliobia, 
mysophobia,  and  the  like.     These  are  true  hypochon- 

Burgical  Electricity  (pp.  285-293)  see  luy  work  ou  Hay-fever  (pp. 

81-86). 

9 


130  NERVOUS  EXHAUSTION. 

driacs  or  pathophobics.  This  pathophobia  is  not  a 
new  disease — it  is,  indeed,  a  very  old  one;  and  I  be- 
lieve that  through  the  increase  in  culture  it  is  relatively 
diminishing;  just  like  the  forms  of  hysteria,  epilepsy, 
and  chorea,  that  were  so  common  in  the  middle  ages. 

Third.  This  true  pathophobia  and  hypochondriasis 
may,  and  often  does,  bring  on  true  objective  disease 
of  the  nervous  system,  or  of  other  parts  of  the  body. 
The  diseases  which  they  bring  on  by  their  worrying 
are  none  the  less  real  because  of  the  subjective  origin, 
but  are  all  the  more  difficult  to  cure;  and  require  treat- 
ment of  a  medical,  as  well  as  of  a  mental  character. 
This  class  of  hypochondriacs  is  very  often  neglected 
and  badly  treated. 

Fourth.  Neurasthenia  in  its  different  varieties,  and 
some  diseases  of  the  stomach  and  the  digestive  and 
reproductive  apparatus,  themselves  excite  hypochon- 
driasis or  pathophobia.  The  patient  not  only  suffers 
from  his  real  disease,  but  from  the  disease  caused  by 
reflex  irritation,  a  fear  that  he  has  what  he  has  not, 
or  that  he  will  have  what  he  is  not  in  danger  of  hav- 
ing. The  mistake  has  been  to  throw  all  symptoms 
that  are  new  to  science,  or  not  well  known,  or  the  ex- 
istence of  which  we  do  not  credit,  into  the  common 
receptacle  of  hysteria  and  hypochondriasis,  whence 
the  quacks  of  all  the  ages  have  drawn  their  support 
and  their  power. 

A  morbid  fear  of  disease  may  be  in  some  instances 
just  as  truly  a  symptom  of  nervous  exhaustion  as  any 
one  of  the  large  number  of  symptoms  described  in  the 
previous  chapter;  and,  Uke  these  other  symptoms,  it 
is  to  be  removed  by  treating  the  cause;  very  properly, 
therefore,  pathophobia  (hypochondria)  is  included 
among  the  other  varieties  of  morbid  fear  as  one  of  the 
manifestations  of  the  neurasthenic  state. 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  131 

If  this  analysis  be  accepted,  it  is  clear  that  few- 
terms  in  medicine  have  been  so  misused,  both  by  the 
laity  and  the  profession,  as  hypochondria. 

General  Hopelessness  and  mental  depression  are 
often  confounded  with  hypochondria;  but  they  are  not 
so,  except  w^hen  they  take  the  special  form  of  morbid 
fear  of  disease. 

The  term  hypochondria,  therefore,  is  practically  and 
constantly  applied  to  the  following  very  different  con- 
ditions: 

1.  Apprehension  of  disease  from  ignorance  purely. 

2.  Simple  mental  depression  without  any  morbid 
fear  of  any  kind. 

3.  Other  foi*ms  of  morbid  fear,  as  of  places  or  society, 
or  contamination,  or  lightning,  or  storms. 

Only  fear  of  disease  is  entitled  to  the  term  hypo- 
chondria or  pathophobia. 

4.  Groundless  Fear  of  Disease. — This  is  the  only 
condition  to  which  the  term  can  be  strictly  applied. 
And  when  this  condition  really  exists,  it  is  often,  if 
not  usually,  one  of  the  many  symptoms  and  results  of 
some  actual  and  demonstrable  disease  which  can  be 
diagnosticated  on  thorr)ugh  examination,  and  relieved 
by  proper  treatment. 

True  hypochondria,  instead  of  being  a  very  common 
disease  as  is  supposed,  is  comparatively  infrequent — 
cei-tainly  not  much  more  common  than  the  other 
fomis  of  morbid  fear,  to  which  it  is  allied  and  with 
wliich  it  is  often  associated. 

Distinguished  from  Cerebral  and  Spinal  Ancemias 
and  Hf/pera^viias. — In  regard  to  the  relation  of  neu- 
rasthenia to  spinal  and  cerebral  anaemia  and  hyperai- 
mia,  it  may  be  said  that  circulatory  disturbances  of 
various  kinds  and  in  varied  degrees  must  of  necessity 
arise  as  results  of  exhaustion  of  the  nerve-centres;  and 


132  NERVOUS  EXHAUSTION. 

it  must  also  be  allowed  that  when  the  brain  or  spine  is 
engorged  with  blood,  or  greatly  deficient  in  blood,  then 
certain  symptoms  are  likely  to  follow  from  such  local 
plethora  or  anaemia,  just  as  dyspepsia  when  once 
excited  becomes  the  centre,  directly  or  reflexly,  of 
numerous  morbid  phenomena;  but  the  anaemia,  the 
hyperaemia,  the  spinal  or  cerebral  irritation,  like  the 
dyspepsia  and  insomnia,  when  broadly  and  philosophi- 
cally studied,  are  branches  of  a  tree,  the  trunk  of 
which  is  impoverishment  of  nerve- force;  and,  in  all 
these  neurasthenic  states,  over-exertion  or  mental  ex- 
citement is  Uable  at  any  time  to  bring  on  engorgements 
of  blood  in  the  spine  or  brain;  there  may  be  rushes  of 
blood  to  the  head  or  spinal  cord,  which  when  they 
occur  become  the  centres  of  symptoms  of  their  own; 
but  to  call  these  rushes  of  blood,  these  flushings  of  the 
face,  the  disease,  is  to  mistake  effects  for  causes. 

The  results  of  treatment  demonstrate  this  in  a  most 
interesting  way,  both  positively  and  negatively;  thus 
you  shall  cure  a  spinal  irritation  ^  without  curing  or 

1  On  this  point  Erb  remarks  as  follows:  "It  cannot  be  denied 
that  this  complaint  has  a  close  resemblance  in  many  respects  to 
spinal  iritation,  .  .  .  and  the  opinion  might  perhaps  be  defended 
that  this  disease  is  essentially,  for  the  male  sex,  that  which  corres- 
ponds with  spinal  irritation  in  females." 

He  does  not,  however,  regard  the  diseases  as  identical,and  says: 
"  It  would  be  very  desirable  to  lay  out  a  better  division  and  class- 
ification of  these  spinal  neuroses,  by  means  of  accurate  classical 
and  symptomatic  study,  in  order  to  promote  the  pathology  of 
such  an  obscure  subject." 

"  The  distinction  from  spinal  irritation  will  often  be  less  easy  to 
make.  ...  It  must  be  admitted  that  there  are  cases  of  ambiguous 
signification  which  stand,  as  it  were,  half-way  between  the  two 
forms  of  disease,  and  possess  somewhat  of  each." 

In  science  the  next  best  thing  to  knowing  is  to  know  that  we 
do  not  know.  This  is  Erb's  position  in  respect  to  the  relation  of 
the  symptom  spinal  irritation  to  neurasthenia.    He  does  not  solve 


DIAGNOSIS  OP  NERVOUS  EXHAUSTION.  133 

even  permanently  relieving  the  patient,  for  the  neu- 
rasthenia remains,  and  is  liable  to  break  out  any  time 
in  the  same  form,  or  in  any  one  of  a  nmiiber  of  forms, 
such  as  cerebral  irritation,  or  insomnia,  or  nervous 
dyspepsia.  The  symptom  of  spinal  irritation  is  indeed 
one  of  the  easiest  symptoms  to  cm'e;  a  few  days  or 
weeks  at  most  may  be  sufficient  to  drive  away  all  the 
tenderness,  while  the  condition  on  which  it  depends, 
and  of  which  it  is  really  a  part,  may  require  months 
of  treatment,  or  in  some  cases  may  be  absolutely  in- 
curable. On  the  other  hand,  all  influences  that  tend 
to  build  up  the  constitution — a  change  to  country  air 
or  travel — will  often  cure  all  these  symptoms  without 
any  special  treatment  of  the  symptoms  of  anaemia  and 
hypersemia.  That  there  may  be  such  states  as  cerebral 
ancPmia,  cerebral  hyperaemia,  cerebral  congestion, 
spinal  anaemia,  spinal  hypera?mia,  and  spinal  conges- 
tion is  undeniable;  and  these  terms  are  in  some  cases 
properly  used.  Such  circulatory  disturbances  of  the 
nerve-centres,  when  they  exist  as  the  chief,  if  not  only, 
factor  in  the  morbid  process,  and  the  cure  of  these 
disturbances  is  a  cure  of  the  patient,  may  properly  be 
called  diseases;  but  in  neurasthenia  these  circulatory 
irregularities  in  the  brain  and  spinal  cord  are  but  in- 
cidents and  results;  their  removal  leaves  the  sufferer 
still  a  sufferer. 

The  whole  set  of  modem  science  is  indeed  now  in 
favor  of  the  view  tliat  I  presented  twelve  years  ago, 
that  innervation  precedes  circulation:  that  the  waves 

the  problem;  but  he  clearly  appreciates,  as  very  few  writers  have 
(lone,  the  need  of  a  Kolution;  and  he  sees  precisely  where  the  con- 
fusion lies,  and  just  what  {jositioM  science  should  attack.  The 
writin^^sof  the  very  latest  authors,  llosenthal  and  De  (Irasset,  are 
full  of  confusion  on  this  <juestion,  of  the  nature  of  spinal  irritation 
and  its  relation  to  neurasthenia,  of  wluch  it  is  really  but  one  of 
on  anny  of  symptoms. 


134  NERVOTJS  EXHAUSTION. 

of  blood  into  the  nerve-centres  or  out  of  the  nerve- 
centres  move  in  obedience  to  the  nerve-force,  as  the 
sea  rises  and  falls  under  the  law  of  gravity. 

Most  strikingly,  this  view  is  brought  out  in  Vulpian's 
researches  in  the  physiology  of  sleep,  according  to 
which  it  seems  to  be  made  quite  clear  that  our  anaGniia 
theory,  and  our  hyperaemia  theory,  that,  by  alterna- 
tion or  in  unison,  have  held  the  world  so  long,  must 
give  way  to  the  nutrition  theory;  it  is  possible  that  we 
may  be  all  wrong,  as  it  is  certain  that  we  do  not  yet 
understand  the  full  mystery  of  cell  nutrition,  but  just 
now  it  is  the  growing,  if  not  the  dominant  philosophy 
in  all  neurological  circles/ 

Malarial  poisoning  frequently  simulates  neuras- 
thenia, and  also  induces  a  special  type  of  the  disease 
which  may  be  called  malarial  neurasthenia.  Like 
malaria  also,  neurasthenia  affects  and  modifies  nearly 
every  other  disease  that  the  j)atient  contracts,  giving 
a  nervous  and  asthenic  character  to  the  symptoms,  just 
as  malaria  makes  other  maladies  periodic. 

Distinguished  from  Anminia. — It  used  to  be  claimed 
— and  by  some  it  is  claimed  even  now — that  neuras- 
thenia is  but  another  term  for  anaemia,  in  other  words, 
that  impoverishment  of  blood  and  impoverishment  of 
nerve-force  are  identical.  The  basis  of  this  confusion 
of  ideas  is  probably  the  fact  that  the  blood  can  be  seen, 
felt,  measured  and  analyzed,  while  nerve-force  can 
only  be  studied  through  its  manifestations. 

The  two  conditions  have  oftentimes  certain  symp- 
toms in  common,  just  as  functional  and  organic  nerve 

^  Erb's  idea  of  the  nature  of  the  disease  is  similar  :  thus,  after 
mentioning  the  anfiemic  and  hypersemie  theories,  and  admitting 
tliem  to  be  unsatisfactory,  he  says:  "  It  seems  most  natural  to 
recur  to  fine  disturbances  of  nutrition  in  the  cord,  such  as  we  are 
still  obliged  to  assume  in  so  many  diseases  of  the  nervous  system." 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION. 


135 


diseases  have  certain  symptoms  in  common ;  but,  in 
the  one  case  as  in  the  other,  there  is  a  radical  and  in- 
herent distinction — a  distinction  that  modifies  not  only 
our  abstract  conception  of  the  disease,  but  our  prog- 
nosis, our  hygiene,  and  our  therapeutics.  Just  as  a 
case  of  organic  nei've  disease,  treated  as  functional,  is 
sm-e  to  disappoint  us,  and  perhaps  injure  more  than 
help  the  sufferer;  so  a  case  of  neurasthenia,  treated 
and  managed  as  a  case  of  anaemia,  is  likely  to  become 
—as  so  many  of  such  cases  do  become— the  oppro- 
brium of  oar  art. 

The  chief  points  in  the  differential  diagnosis  of  neu- 
rasthenia and  anaemia  are  presented  in  the  following 
table: 


Neurasthenia. 

Chiefly  found  in  nervous  dia- 
thesis. 


Impoverishment  of  nervous 
system;  no  necessary  anaemia. 
Patient  may  he  plethoric. 

Found  chiefly  between  the 
ages  of  fifteen  and  sixty. 

Not  at  all  necessarily  depen- 
dent on  any  important  recog- 
nizable organic  disease. 


Pulse  may  be  full  or  normal, 
but  sometimes  very  rapid  or 
very  slow. 

No  cardiac  murmurs. 


No  pallor— sometimes  even  a 
rubicund  appearance. 


Anoemia. 

Appears  also  in  the  tubercu- 
lous, or  rheumatic,  or  other 
diathesis. 

Impoverishment  of  the  blood ; 
increase  of  water,  and  diminu- 
tion of  red  corpuscles. 

Found  in  all  periods  of  life, 
from  extreme  infancy  to  old 
age. 

More  frequently,  though  not 
necessarily,  associated  with 
some  organic  disease,  as  tuber- 
culosis, carcinoiua,  morbus 
Brightii,  etc. 

Pulso  small,  weak,  and  com- 
pressible. 

Murmurs  at  the  base  of  the 
lieart  and  over  the  largo  arter- 
ies, as  the  carotid,  Huhclavian, 
etc.  "Venous  hum"  in  the 
neck. 

Very  perceptible  jiallor  of 
the  face,  especially  of  tlic  lips. 


136 


NERVOUS  EXHAUSTION. 


Neurasthenia. 

Easily  fatigued  by  exertion; 
mental  labor  in  eerebrasthenia 
more  exhausting  than  physi- 
cal. Memory  often  temporari- 
ly weakened,  and  consecutive 
thought  and  sustained  mental 
activity  frequently  impossible, 
even  when  prolonged  muscAilar 
labor  causes  little  or  no  fatigue. 

Insomnia  a  very  frequent 
complication. 


No  necessary  or  constant  dis- 
turbance of  the  circulation. 

Habitual  mental  depression. 

Though  common  to  both 
sexes,  not  so  relatively  frequent 
in  females. 

Is  benefited  by  remedies  that 
directly  affect  the  nervous  sys- 
tem, such  as  electricity,  count- 
er-irritation, strychnine,  zinc, 
and  oil,  while  iron  alone  is  of 
little  service. 

Usually  recovers,  but  gradu- 
ally, and  under  the  influence 
of  rest,  nutritious  food,  and 
various  sedatives  and  tonics. 


Ancemia. 
Easily  fatigued  by  exertion. 
Physical  labor  always  more  ex- 
hausting than  mental. 


Insomnia  not  so  frequent  a 
complication,  frequently  an 
abnormal  tendency  to  sleep  by 
day  as  well  as  by  night. 

Disturbance  of  the  circula- 
tion, with  habitually  cold  ex- 
tremities. 

Mental  depression  not  so  fre- 
quent. 

Far  more  frequent  in  fe- 
males. 

Is  benefited  by  remedies  such 
as  iron,  that  directly  affect  the 
blood. 


May  be  rapidly  removed  by 
the  removal  of  the  organic 
cause. 


Distinguished  from  Hysteria.  — From  hysteria,  neu- 
rasthenia is  distinguished  in  part  by  the  absence  of 
the  convulsions  or  paroxysms  that  are  always  regarded 
as  peculiar  to  the  hysterical  state. 

Neurasthenia,  like  ancemia,  may,  it  is  true,  lead  to 
hysteria  as  it  may  lead  to  insanity;  but  hysteria,  when 
it  appears,  is  with  all  its  group  of  symptoms,  including 
the  hysterical  convulsions  or  paroxysms,  and  the 
globus  hystericus,  or  feeling  as  of  a  ball  in  the  throat, 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  137 

quite  a  distinct  condition.  In  hysteria  there  are  some 
of  the  symptoms,  besides  the  paroxysms,  an  acuteness, 
violence,  activity,  and  severity  that  do  not  belong  to 
simple  neurasthenia. 

Hysteria  is  found  usually  in  those  whose  emotional 
natures  greatly  predominate.  Hence,  relatively  to 
neurasthenia,  it  is  far  more  common  in  females  than 
in  males.  Indeed,  hysteria  was  once  supposed  to  be 
exclusively  a  disease  of  women;  hence  its  name. 
Neurasthenia,  on  the  other  hand,  although  more  fre- 
quent in  women,  is  yet  found  in  gi-eat  abundance  in 
both  sexes,  and  iri  both  men  and  women  of  intellect, 
education,  and  well-balanced  mental  organizations. 

Hysteria  of  the  mental  or  psychical  form  may  occm* 
in  those  who  are  in  perfect  physical  health,  without 
any  of  the  symptoms  of  neurasthenia  or  of  anaemia; 
those  of  the  strongest  possible  constitutions  are  the 
victims  of  this  type  of  hysteria,  the  subjective  psycho- 
logical cause  of  which  is  an  excess  of  emotion  over  in- 
tellect, acted  upon  by  any  influence  that  tends  to  pro- 
duce emotional  excitation.  This  form  of  hysteria  is 
found  in  the  stout  Irish  servant  girls,  among  the 
Southern  negroes,  and  among  the  midisciplined  and 
weak-minded  of  all  races  and  classes  and  ages,  and, 
unlike  neurasthenia,  was  more  prevalent  in  the  middle 
ages  than  in  the  nineteenth  century. 

Lastly,  hysteria,  whether  of  the  mental  or  physical 
type,  or  of  both  tjrpes  combined,  may,  and  often  does, 
completely  recover  suddenly,  and  may  disappear  under 
purely  subjective  or  mental  treatment.  Neurasthenia 
never  recovei-s  suddenly,  but  usually  requires  much 
time,  whatever  treatment  may  be  employed;  and 
though,  like  all  other  morbid  states,  it  can  be  power- 
fully influenced  by  mental  therapeutics,  yet  demands 
usually  positive  and  varied  objective  treatment. 


138 


NERVOUS   EXHAUSTION. 


The  differences  between  neurasthenia  and  hysteria 
appear  more  distinctive  when  tabulated  side  by  side, 
as  follows: 


Neurasthenia. 
No  convulsions  or  paroxj^sms. 

No  globus  hystericus,  no  anses- 
tliesia  of  the  epiglottis,  ovarian 
tenderness  less  eouimon,  and 
attacks  of  ansesthesia  far  less 
frequent  and  less  permanent. 

Symptoms  more  moderate, 
quiet,  subdued,  passive. 

May  occur  in  well-balanced, 
intellectual  organizations. 

Very  common  in  males, 
though  more  common  in  fe- 
males. 

Is  always  associated  with 
physical  debility. 

Never  recovers  suddenly,  but 
always  gradually,  and  under 
the  combined  influences  of  hy- 
giene and  objective  treatment. 


Hysteria. 

Hysterical  convulsions  or 
paroxysms. 

Globus  Hystericus,  anaesthe- 
sia of  the  epiglottis,  ovarian 
tenderness,  and  attacks  of  gen- 
eral or  local  anaesthesia. 

Symptoms  acute,  intense, 
violent,  positive. 

Usually  associated  with  great 
emotional  activity  and  unbal- 
anced mental  organization. 

Very  rare  in  males. 


In  the  mental  or  psychical 
form  occurs  in  those  who  are  in 
perfect  physical  health. 

May  recover  suddenly  and 
under  purely  emotional  treat- 
ment. 


[Distinguished  from  Lithcemia. — The  relationship  of 
neurasthenia  to  lithaemia  has  long  seemed  to  me  to  be 
of  the  utmost  imj^ortance,  and  to  have  been  unac- 
countably neglected  in  the  consideration  of  both  con- 
ditions. 

A  patient  consults  his  physician  complaining  of  neu- 
rasthenia, for  which  he  has  been  treated  for  a  long 
time  without  benefit.  Now  neurasthenia  is  a  disease 
by  no  means  incurable,  and  the  fact  that  no  benefit  had 
been  derived  leads  him  to  doubt  the  diagnosis.  True 
enough,  a  more  careful  examination  reveals  evidences 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  139 

of  intestinal  and  liver  indigestion,  and  an  abundance  of 
uric  acid  in  the  urine.  For  years  the  patient  has  per- 
haps taken  but  little  exercise,  and  indulged  his  appetite 
without  restraint.  Under  a  complete  reversal  of  this 
order  of  affairs — more  exercise  in  the  open  air,  simpler 
diet,  simple  remedies  directed  towards  correcting  the 
disordered  digestive  function — many  of  his  most  per- 
sistent and  annoying  symptoms  quite  disappear. 
Every  general  practitioner  could,  I  doubt  not,  duplicate 
many  times  such  cases  as  this;  and  yet,  on  the  con- 
rary,  how  often  has  the  neurologist  been  called  upon 
to  deal  with  just  the  reversal  of  this  state  of  things, 
where  a  typical  neurasthenic  has  been  regarded  as 
simply  hypochondriacal,  and  treated  with  alteratives 
and  purges  for  a  supposed  torpidity  of  the  liver. 

The  fact  that  l)oth  neurasthenia  and  lithaemia  are  so 
frequent,  that  there  is  such  an  apparent  similarity  of 
symptoms,  and  above  all  that  they  demand  methods 
of  treatment  so  radically  diverse,  impels  me  to  relate 
two  cases,  each  of  them  typical  of  the  class  to  which  it 
belongs,  and  both  of  them  illustrating  most  effectively 
the  necessity  of  a  correct  diagnosis  as  a  guide  to  proper 
methods  of  treatment. 

Case  of  Neurasthenia. — Mr.  O.,  aged  tliirty-six,  con- 
sulted me  for  symptoms  that  had  for  the  past  five  or 
six  years  greatly  interfered  with  his  happiness  and 
capacity  for  work.  Physically  he  was  well  developed, 
standing  five  feet  ten  inches  in  his  stockings,  and 
weighing  l7o  pounds.  His  complexion  was  fair,  his 
eyes  were  blue,  his  liair  was  blonde,  and  his  nutrition 
was  apparently  unimpaired. 

Intellectually  he  was  far  above  the  average.  He 
could  speak  correctly  in  two  languages  other  than  liis 
own,  besides  understanding  and  writing  a  third,  and 
all  this  he  had  mostly  acquired  through  self -instruction. 


140  NERVOUS  EXHAUSTION. 

In  addition  to  the  labor  necessitated  by  these  scholastic 
acquirements,  he  had  devoted  himself  for  years,  with 
few  intervals  of  rest,  to  the  details  of  an  exacting 
mercantile  business.  The  symptoms  to  be  described 
were  essentially  the  same  as  those  he  had  suffered 
from  for  the  past  five  years. 

He  complained  first,  and  perhaps  most  of  all,  of  a 
settled  melancholia,  associated  with  a  morbid  and 
utterly  baseless  fear  of  financial  iniin,  and  yet  he  was 
by  no  means  ill-tempered  or  irritable.  On  the  con- 
trary, he  was  in  his  most  depressed  moods  a  model  of 
dignity  and  gentle  demeanor.  His  pulse  was  30  or 
more  and  somewhat  irregular,  rendering  him  fearful 
of  heart  disease;  but  this  was  only  one  of  a  number 
of  morbid  fears  that  had  from  time  to  time  distressed 
him.  His  appetite  was  fair  at  all  times,  and  his  weight 
varied  but  little  from  year  to  year.  Constipation  was 
a  somewhat  troublesome  symptom. 

He  looked  strong,  and  yet  he  was  as  easily  exhausted 
physically  as  mentally.  He  possessed  no  reserve  force, 
and  gave  out  utterly  whenever  he  attempted  to  over- 
step the  bounds  of  the  most  ordinary  effort.  At  one 
time  his  eyes  would  be  bloodshot,  and  at  another  per- 
fectly natural,  showing  a  tendency  to  local  and  tran- 
sient hyperasmia,  due  principally  to  innervation. 

Misled,  perhaps,  by  the  constipation  from  which  he 
suffered,  the  medication  to  which  he  had  been  sub- 
jected had  been  directed  in  good  measure  toward  cor- 
recting the  function  of  food  assimilation,  but  with  no 
marked  effect.  To  this  time  he  had  not  given  up  the 
general  supervision  of  his  business,  but  soon  after 
coming  under  my  observation  he  was  induced  to  leave 
New  York  indefinitely.  He  jom^neyed  to  the  West, 
visited  the  Yellowstone  region,  and  at  San  Francisco 
took  steamer  for  China.    He  was  absent  some  eighteen 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  141 

months,  and  returned  a  well  man,  nor  has  he  since  re- 
lapsed into  his  former  condition. 

This  case  I  regard  as  one  of  neurasthenia  pure  and 
simple.  The  patient  needed  no  remedy  directed  to  the 
liver,  to  the  bowels,  or  to  any  special  function.  If  he 
had  been  unable  to  pursue  the  course  he  did,  remedies 
directed  to  the  restoration  of  the  impoverished  nerve- 
force  would  have  been  in  order,  and  not  cholagogue 
cathartics  or  bitter  tonics.  What  he  needed  above  aU 
things  was  absolute  rest  for  the  exhausted  nerve- 
forces,  and  an  entire  change  of  air  and  scene.  All 
cases  of  neurasthenia  are  by  no  means  so  wonderfully 
benefited  by  rest  and  change  of  scene.  I  have  repeat- 
edly had  neurasthenic  patients  who  had  traveled  ex- 
tensively and  failed  to  be  greatly  benefited  until  the 
impoverished  nerve  force  had  been  improved  by  suit 
able  forms  of  treatment.  Subsequently,  travel  may  be 
resoi-ted  to  with  profit  and  pleasure.  The  exhaustion 
that  results  from  any  excessive  strain  upon  the  men- 
tal and  physical  powers  is  simply  an  attack  of  acute 
neurasthenia,  and  differs  from  chronic  neurasthenia 
very  much  as  any  acute  attack  differs  from  its  chronic 
form.  It  is  a  question  only  of  permanence  and  degree, 
hut  the  basis  of  both  is  impoverishment  of  nervous 
force,  and  waste  of  nerve- tissue  in  excess  of  repair. 

As  illustrative,  on  the  other  hand,  of  the  lithicmic 
condition,  I  offer  the  following  case: 

Mr.  N.,  aged  forty-three,  a  stout  gentleman  with  a 
somewhat  sallow  complexion,  consulted  me  for  a 
variety  of  symptoms  whicli  ho  su})p()se(l  to  be  neuras- 
thenic, and  for  the  relief  of  which  he  had  taken  many 
"nerve-tonics,"  together  witli  a  "course  of  electric- 
ity," but  with  no  appreciable  benefit.  He  suffered 
from  periodical  attacks  of  constipation,  and  at  these 
times  he  became  so  depressed  and  irritable  as  to  render 


142  NERVOUS  EXHAUSTION. 

his  family  exceedingly  uncomfortable.  He  himself 
suffered  most  of  all  from  this  lack  of  mental  control, 
and  deplored  it  beyond  measure.  For  his  constipation 
he  had  been  accustomed  to  take  much  fruit  and  to  rely 
on  the  saline  waters,  but  gave  little  heed  to  his  diet, 
eating  heartily  of  whatever  he  liked,  and  invariably 
taking  wine  with  his  dinner.  He  slept  well,  and  when 
by  the  use  of  these  waters  or  after  an  attack  of  diar- 
rhoea the  clogged  system  became  in  a  measure  un- 
loaded, he  felt  as  well  and  as  activ^e  as  ever.  Several 
examinations  of  his  urine  rev^ealed  the  fact  that  when 
he  was  constipated  and  depressed  uric  acid  was  present 
in  abundance,  but  when  his  bowels  moved  freely  and 
he  was  feeling  fairly  well  hardly  a  trace  could  be 
found.  Noises  in  the  ear  were  a  most  annoying  symp- 
tom, ceasing  when  the  urine  cleared,  and  invariably 
coming  on  in  full  force  with  the  appearance  of  uric 
acid. 

When  it  was  explained  to  this  patient  that  he  was 
not  in  any  way  neurasthenic,  but  that  the  cause  and 
cure  of  his  distressing  symptoms  depended  largely  if 
not  altogether  upon  his  food  and  drink  and  his  habits 
of  exercise,  the  statement  seemed  a  revelation  to  him. 
He  readily  consented  to  a  great  decrease  in  the  albu- 
minoid forms  of  food,  total  abstinence  from  alcohohc 
stimulants,  and  out-of-door  exercise  by  walking  for  at 
least  five  miles  each  day. 

No  medication  was  attempted  through  the  whole 
course  of  this  regime,  unless  the  occasional  dose  of  a 
third  of  a  tumbler  of  Eubinat  water  could  be  thus 
designated. 

Under  this  dietetic  change  and  increased  bodily  ex- 
ercise the  improvement  in  the  condition  of  this  patient 
was  radical  and  rapid.  The  action  of  his  bowels  be- 
came regular  and  free,  and  in  saying  this  all  is  said  as 


DIAGNOSIS   OF  NERVOUS   EXHAUSTION.  14r3 

regards  his  other  symptoms.  The  condition  of  his 
bowels  was  the  index  of  his  mental  and  physical  con- 
dition. When  he  was  constipated,  uric  acid,  the  prod- 
uct of  imperfect  oxygenation,  invariably  appeared  in 
the  urine,  associated  with  cold  hands  and  feet,  noises 
in  the  ears,  lieaviness  or  rather  a  sense  of  constriction 
about  the  head,  and  excessive  irritability  of  temper. 
With  the  relief  of  the  constipation  all  tliese  symptoms 
disappeared,  and  so  long  as  he  faithfully  follows  the 
prescribed  method  of  living  his  f mictions  are  properly 
performed. 

Functional  diseases  of  the  ner^'^ous  system,  and  in- 
deed all  forms  of  functional  dei'angemont,  are  perhaps 
practically  more  important  for  our  consideration  than 
those  that  are  organic  or  structural  in  character.  Long 
experience  has  taught  us  how  very  little  all  our 
boasted  therapeutics  amounts  to  in  dealing  with  any 
progressive  degeneration  of  nerve-tissue. 

Jolin  Quincy  Adams,  referring  to  himself  a  short 
time  before  his  death,  said  that  the  house  was  tumb- 
hng  to  pieces  and  the  landlord  refused  to  make  further 
repairs.  In  the  degenerative  changes  brought  on  by 
disease,  by  injuries,  or  excesses,  very  much  the  same 
rule  prevails,  and  when  nature  withholds  her  aid  our 
art  is  practically  powerless.  With  what  in  our  igno- 
rance we  term  functional  diseases  the  case  is  widely 
different;  nature  stands  ever  ready  to  aid  in  the  cure 
if  only  the  opportunity  be  given.  Neurasthenia  is  a 
functional  disaase,  and  ouglit  never  to  l)e  mistaken  for 
organic  disease  of  tlie  nervous  system,  and  seldom  is, 
except  by  the  patient  himself,  and  therefore  no  mis- 
takes of  treatment  nned  follow  in  this  connection;  it 
is,  however,  fre(|uently  mistaken  for  litha^nia  and 
other  faults  of  assimilation,  which  lead  to  radical  errors 
of  treatment.     It  might  be  suggested  that  the  presence 


144  NERVOUS   EXHAUSTION. 

of  uric  acid  in  the  urine  ought  to  be  a  sufficient  diag- 
nostic sign,  but  uric  acid  is  found  in  neurasthenic 
patients  and  is  not  at  all  times  found  in  the  lithaemic. 

Other  objective  as  well  as  subjective  symptoms 
therefore  enter  as  no  unimportant  factors  in  aiding 
toward  a  correct  diagnosis. 

According  to  my  own  experience,  one  of  the  most 
common  and  distinctive  points  of  differential  diagnosis 
between  lithaemia  and  neurasthenia  is  the  difference 
in  the  character  of  the  mental  phenomena.  Both  the 
lithsemic  and  the  neurasthenic  suffer  from  mental 
depression  and  a  profound  sense  of  misery,  more 
marked  indeed  in  the  former  than  in  the  latter  condi- 
tion. Wliile,  however,  the  neurasthenic  may  suffer 
from  the  deepest  melancholy,  and  imagine  himself 
heir  to  a  thousand  ills,  he  becomes  the  victim,  as  a 
rule,  of  no  such  irritability  and  unreasonable  outbursts 
of  temper  as  the  man  whose  brain  is  actually  poisoned 
by  the  imperfectly  transformed  products  of  digestion. 
The  neurasthenic  may  be  at  times  extremely  irritable, 
but  this  irritabihty  is  more  passive  than  active,  and 
any  ebullition  of  angry  feeling  is  quite  evanescent. 
His  demeanor  is,  as  a  rule,  quiet,  and  there  is  but  little 
manifest  tendency  to  make  those  dependent  upon  him 
miserable  by  his  words  and  actions.  The  touchy 
mood  of  the  htha?mic,  on  the  contrary,  may  last  for 
days  or  weeks.  It  is  due  to  actual  toxaemia,  is  often 
if  not  generally  accompanied  by  obstinate  constipation, 
and  may  be  relieved  coQipletely  by  the  action  of  a 
cholagogue  cathartic. 

In  neurasthenia,  again,  cold  hands  and  feet  are  not 
by  any  means  the  rule,  but  in  intestinal  and  liver  de- 
rangements the  nitrogenized  wastes  circulating  in  the 
blood  cause,  by  their  irritation,  tonic  spasm  of  the 
arterioles,  resulting  in  the  cold  hands  and  feet  so  bit- 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  145 

terly  complained  of  by  the  sufferers  from  lithaemia. 
The  condition  of  the  tongue  is  an  important  diagnostic 
aid.  In  Uthaeraia  it  is  coated  far  more  frequently  and 
to  a  greater  extent  than  in  neurasthenia,  but  in  some 
cases  of  hthsemia  the  tongue  is  but  shghtly  affected. 
It  may  appear  at  first  sight  perfectly  normal,  and  it  is 
only  when  looked  at  carefuUy  from  the  side  that  an 
unnatural  brownish  color  is  observed.  It  is  in  such 
cases  as  this  that  mistakes  in  diagnosis  are  frequently 
made.  As  regards  the  pulse,  it  may  be  said  that  in 
lithaemia  it  is  slow  rather  than  fast,  and  in  neuras- 
thenia fast  rather  than  slow.  In  neurasthenia  the 
oxalates  are  frequently  found  in  abundance,  while  in 
lithaemia  the  oxalates  are  not  usual. 

No  one  example  of  neurasthenia  illustrates  more 
than  a  very  small  fraction  of  the  great  army  of  symp- 
toms that  have  been  observed  in  connection  with  this 
disease,  and  it  is  for  this  reason  that  so  many  have 
expressed  doubts  as  to  the  propriety  of  any  such  for- 
mulation as  neurasthenia. 

On  the  other  hand,  making  allowances  for  constitu- 
tional differences  and  occasional  aggravated  fonns, 
cases  of  lithaemia  are  very  much  alike,  and  when  one 
has  seen  a  few  such  cases  he  has  seen  them  all. 

If  it  were  practicable  to  take  a  hundred  cases  of 
neurasthenia  and  write  the  sum-total  of  symptoms, 
objective  and  subjective,  and  do  Ukewise  with  the 
same  number  of  litlia^mic  cases,  the  result  would  be 
an  interesting  study— indicating  that,  in  the  fullness 
of  their  manifestation,  the  two  conditions  are  symp- 
tomatically  very  wide  apart,  however  similar  they 
may  ai)pear  when  compared  singly. 

The  treatment  of  neumsthenia  and  lithaemia  is  as 
widely  different  as  their  nature  and  causation.  In  the 
management  of  individual  examples  of  both  these 
10 


146  NERVOUS   EXHAUSTION. 

conditions  the  minor  treatment  is  often  necessarily 
varied  to  meet  special  annoying  symptoms. 

In  lithsemia,  for  example,  constipation  may  be  met 
by  the  moderate  use  of  mineral  waters,  especially  of 
the  Carlsbad  and  Rubinat  varieties,  because  of  the 
large  amount  of  sulphate  of  sodium  they  contain,  and 
occasionally  more  active  cholagogue  cathartics  can  be 
used  with  advantage.  The  natural  lithic  waters  are 
also  of  value  and  always  in  order.  As  for  neuras- 
thenia, the  remedies  suggested  for  its  relief  are  as 
numerous  as  the  symptoms  which  it  presents,  and 
their  enumeration  alone  would  fill  a  page. 

If  we  once  fully  appreciatB  the  fact  that  the  two 
diseases  demand  diametrically  opposite  methods  of 
treatment,  that  the  relief  of  lithaemia  in  great  measure 
depends  upon,  as  it  is  caused  by,  the  food  we  eat  and 
what  we  drink,  as  well  as  habits  of  exercise,  and  that 
neurasthenia  is  caused  by  worry  and  work  and  nerv- 
ous strain,  our  knowledge  of  the  effects  of  food  in  the 
organism,  together  with  the  exercise  of  ordinary  sense 
and  j  udgment,  will  enable  us  to  deal  intelligently  with 
both  these  conditions.] 

Distinguished  from  Syphilis. — Syphihs  sometimes 
simulates  neurasthenia;  the  irregularity  of  many  of 
its  phenomena,  such  as  sudden  loss  of  power  of  one 
hmb  or  of  several  hmbs — coming  and  going — tingling 
and  numbness  in  the  extremities,  cramp  and  twitch- 
ings  of  the  muscles,  especially  at  night,  disturbances 
of  the  special  senses,  transient  and  curable  impotence 
— all  suggest  neurasthenia,  and  of  themselves  alone  are 
not  sufficient  to  enable  us  to  make  out  a  diagnosis  of 
syphilis.  The  syphilitic  origin  of  such  symptoms  is 
established  by  these  four  considerations: 

1.  The  history  of  the  case. 

2.  Other  symptoms  of  syphilis. 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  147 

3.  The  temperament  of  the  patient.  Other  factors 
being  equal,  the  nervous  diathesis  would  give  a  prob- 
ability of  neurasthenia,  although  nervous  syphilis 
does  appear  in  the  nervous  and  sensitive, 

4.  The  results  of  anti-syphihtic  treatment.  This  is 
the  conventional  mode  of  making  a  diagnosis  in  sus- 
pected syphilis;  but  in  the  question  under  considera- 
tion it  is  not  necessary  to  resort  to  it. 

Syphilis  may  simulate,  not  only  neurasthenia,  but 
even  absolute  hysteria.  I  have  known  a  syphilitic 
patient  to  go  rapidly  through  a  series  of  hysterical 
phenomena— transient  paralysis,  flying  all  about  the 
body ;  one  hour  aphasia,  another  paralysis  of  the  arm 
or  leg,  or  aphonia,  and  so  forth.  Dr.  Althaus,  of  Lon- 
don, reports  similar  experiences. 

Distinguished  from  Common  Cold  and  Rheumatism. 
— Neurasthenia  sometimes  simulates  in  a  perfect  and 
most  interesting  way  the  symptoms  of  a  common  cold 
— the  chilliness,  the  positive  coldness,  the  tremor,  the 
heaviness  and  soreness  of  the  back,  bones,  and  limbs, 
and,  in  some  cases,  excessive  secretion  from  the  eyes 
and  nostrils,  all  may  exist  together  in  a  neurasthenic 
sufferer,  and  in  some  cases  only  time  can  determine 
whether  a  cold  has  been  taken  or  not. 

Neurastbenia  also  may  simulate  rheumatism,  and 
is  frequently  mistaken  for  it.  Thus  the  stiffness  of 
the  neck,  when  the  upper  poi-tion  of  the  spine  is  in  an 
irritable  condition,  or  of  the  loins  and  lumbar  region 
when  the  lower  part  of  the  cord  is  irritated,  at  once 
suggests  rheumatism. 

Differential  Difir/nosis  of  Corehrasthenia  {Brain 
Exhaustion)  and  Myelastlieina  (Spinal  Krhanstioii). — 
Both  for  the  hygiene  and  the  therapeutics  of  neuras- 
thenia, it  is  ner(^ssary  to  be  abl(^  to  make  a  projior  dif- 
ferential diagnosis  between  cerebrasthenia  (exhaustion 


148  NERVOUS  EXHAUSTION. 

of  the  brain)  and  myelasthenia  (exhaustion  of  the 
cord).  In  my  original  paper  (in  1869)  no  such  distinction 
was  attempted.  The  symptoms  that  suggest  cerehras- 
thenia  are  obviously  those  that  are  directly  or  indirectly 
connected  with  the  head,  and  they  may  be  either 
physical  or  psychical.  Tenderness  of  the  scalp,  a  feel- 
ing of  fullness  in  the  ears  and  head,  all  disorders  of 
the  special  senses,  tenderness  of  gums,  deficient  thirst, 
morbid  desire  for  stimulants  aud  narcotics,  gaping, 
yawning,  rushes  of  blood  to  the  head,  congestion  of 
conjunctiva,  the  different  forms  of  morbid  fear,  men- 
tal depression  and  impairment  of  memory  and  intellec- 
tual control,  all  indicate  that  the  brain  is  chiefly 
affected.  Certain  symptoms,  however,  as  external 
tenderness  of  the  scalp,  general  or  local  itching,  clam- 
miness of  the  extremities,  muscae  volitantes,  pain  and 
heaviness  in  the  back  of  the  head,  may  arise  from 
exhaustion  of  the  upper  part  of  the  spine.  The  symp- 
toms that  suggest  myelasthenia  or  spinal  exhaustion 
are  local  spasms  of  muscles,  local  chills  and  flashes  of 
heat,  shooting  pains  in  the  limbs,  startings  on  falling 
to  sleep,  morbid  sensations  at  the  bottoms  of  the  feet, 
as  of  burning  or  tenderness,  vague  pains  in  the  feet, 
podalgia,  sexual  debility  in  its  various  phases,  pain  in 
the  back — any  part  of  it  from  the  nape  of  the  neck  to 
the  tip  of  coccyx  with  or  without  the  accompaniment 
of  spinal  irritation— creeping  and  crawhng  sensations 
up  and  down  the  spine,  incontinence  of  urine  or  pare- 
sis of  the  bladder,  feeling  of  pressure  in  the  chest  with 
or  without  tickhshness  in  that  region,  heaviness  and 
stiffness  of  the  muscles  simulating  rheumatism,  sen- 
sitiveness to  cold  and  changes  in  the  weather,  dryness 
of  skin  or  morbid  perspiration,  dryness  of  the  joints, 
and  dilated  pupils. 

Some  other  symptoms,  as  nervous  dyspepsia,  con- 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  149 

stipation,  flatulence,  numbness  and  liyperaesthesia,  and 
insomnia,  appear  to  be  common  to  both  states,  since 
they  manifest  themselves  when  either  cerebrasthenia 
or  myelasthenia  is  uppermost. 

No  other  single  fact  so  much  aids  us  in  making  out 
the  differential  diagnosis  as  this,  that  in  myelasthenia 
physical  exercise,  especially  walking  and  standing,  but 
oftentimes  any  form  of  muscular  exertion  requiring 
either  the  upper  or  the  lower  limbs,  is  fatiguing  and 
disagreeable,  and  when  kept  up,  is  hable  to  make  the 
patient  worse  and  interfere  with  the  treatment.  In 
cerebrasthenia,  on  the  other  hand,  severe,  and  violent, 
and  long-kept-up  muscular  exertion  can  be  well  borne, 
and  is  frequently  desired  and  sought  for;  indeed,  with 
such  patients  this  desire  for  physical  effort  and  activity 
sometimes  becomes  a  morbid  symptom,  and  demands 
restraint.  Those  whose  brains  are  diseased  even  to 
the  border  land  of  insanity,  can,  in  some  instances, 
do  far  more  physically,  with  far  less  fatigue,  than 
when  in  their  usual  health. 

"Whence  I  derive  this  practical  rule  for  the  differen- 
tial treatment  of  cerebral  and  spinal  exhaustion — 
namely,  that  in  cerebral  exhaustion  {cerebrasthenia) 
active  muscular  exercise  in  reasonable  amount  and 
variety  may  be  allowed  and  enjoined;  in  spinal  ex- 
haustion {myelasthenia),  relative  and  in  some  cases 
absolute  rest  is  demanded  or  only  passive  exercise,  for 
a  shorter  or  lontjer  time,  as  may  be,  according  to  the 
special  pecidiar it ies  of  the  individual. 

A  neglect  of  this  cardinal  distinction,  a  want  of 
knowledge  of  the  differential  symptoms  of  nervous 
exhaustion  chiefly  centred  in  the  brain,  and  nervous 
exhaustion  chiefly  centred  in  the  spine,  is  the  constant 
source  of  errors  in  the  advice  given  to  pntients,  and 
in  the  regimen  that  patients  prescribe  for  themselves. 


150  NERVOUS  EXHAUSTION. 

Cerebrasthenia  and  myelasthenia  are  very  often 
combined,  and  not  unfrequently  alternate  with  each 
other.  These  facts  yet  further  complicate  both  the 
diagnosis  and  treatment;  at  one  stage  of  neurasthenia, 
a  patient  may  be  able  to  ta,ke  large  amounts  of  muscu- 
lar exercise;  at  another  stage — separated,  it  may  be, 
by  not  more  than  a  few  days  or  weeks — all  muscular 
activity  is  irksome  and  injurious,  and,  if  persisted  in, 
may  do  harm.  Hence  it  follows  that  patients  must  be 
watched  and  studied  by  the  physician  so  that  the 
hygiene  may,  to  a  certain  extent,  be  varied  with  the 
different  phases  of  the  disease. 

To  indiscriminatingly  advise  such  patients  to  work 
furiously  in  the  open  air,  'as  is  so  often  done,  or  to 
advise  them  to  go  to  bed  and  keep  in  bed,  as  is  also 
done — to  the  extent  of  confining  them  in  a  dark  room 
—  is  Ukewise  unscientific,  and  may  do  mischief;  indeed, 
as  practised  years  ago,  the  dark-room  treatment  cer- 
tainly did  not  a  little  evil;  it  was  an  empirical  employ- 
ment of  a  really  good  therapeutic  measure.  There  are 
cases  of  neurasthenia  where  confinement  to  bed  is  the 
very  best  possible  treatment;  there  are  cases  when  it 
is  the  very  worst  possible  treatment. 

Pathology  and  Rationale. — In  regard  to  the  pathol- 
ogy of  neurasthenia,  my  view,  as  expressed  in  my  first 
paper  on  the  subject,  is,  that  there  is  an  impoverish- 
ment of  the  nerve -force,  resulting  from  bad  nutrition 
of  the  nerve-tissue  on  the  metamorphosis  of  which 
the  evolution  of  nerve- force  depends;  as  in  anaemia, 
there  may  be  a  deficiency  in  quantity  or  impairment 
of  quality  of  the  blood;  so  in  neurasthenia  there  is, 
without  question,  deficiency  in  quantity  or  impairment 
in  quahty  of  the  nerve-tissaes;  hence  the  exhaustion, 
the  positive  pain,  the  unsteadiness,  the  fluctuating 
character  of  the  morbid  sensations  and  phenomena  to 
which  the  term  neurasthenia  is  applied. 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  151 

In  neurasthenia,  the  balance  between  waste  and  re- 
pair is  not  justly  maintained  in  the  central  nervous 
system,  however  it  may  be  in  other  parts  of  the 
body. 

The  patient  may  be  fleshy,  may  weigh  more  than 
when  in  health;  but  it  is  not  unreasonable  to  believe 
that  the  expenditure  of  nerve-matter  is  sometimes 
greater  than  the  supply,  and  that,  consequently,  there 
is  a  constant  poverty  of  nerve  force. 

It  is  certain  that  there  is  an  instability  of  the  nerv- 
ous system,  as  the  symptoms  show,  and  notably  in 
extreme  cases  that  have  gone  on  to  neurasthenia  and 
hystero-epilepsy. 

In  these  cases,  everything  is  changing — there  is  con- 
stant oscillation — the  essential  factor  in  these  cases  in- 
deed being  perpetual  mutation  from  bad  to  worse,  or 
vice  versa,  from  day  to  day,  and  in  some  cases  from 
hour  to  hour. 

Vaso- Motor  Reflexes. — One  of  the  most  interesting 
and  suggestive  of  all  the  facts  connected  witli  neuras- 
thenia is  the  part  whicli  the  vaso-motor  system  plays 
in  reflex  action.  The  blood-vessels  are  supplied  with 
vaso-motor  nerves,  which  are  connected  with  the  spinal 
cord.  The  heart  also  is  supplied  with  vaso-motor 
nerves,  and  has  besides  an  exceedingly  complex  and 
varied  nerve-supply-  the  accelerator  nerves,  the  vagus, 
and  the  depressor. 

Wlien  we  consider  these  facts,  we  flnd  an  explana- 
tion of  tlie  clinical  fact  that  in  cases  of  neurastlienia 
the  heart  is  so  frequently  affected.  The  so-called  irri- 
taltle  heait,  corresponding  to  irritable  breast,  irritable 
spine,  irritable  ovary,  is  indeed  one  of  the  most  com- 
mon of  all  the  symptoms  of  neurasthenia.  There  are 
very  few  cases  of  long  standing  neurasthenia  wlio  do 
not,  at  some  stage  or  other  of  this  disease,  suffer  from 


152  NERVOUS  EXHAUSTION. 

cardiac  palpitation  or  oppression,  or  from  a  morbidly 
slow  or  rapid  pulse.  These  symptoms,  in  truth,  are 
more  frequent  than  perhaps  almost  any  other,  and 
drive  certain  patients  of  this  class  to  the  physician  for 
consultation;  they  fear  that  they  have  organic,  incur- 
able heart-disease,  and  it  is  one  of  the  most  difficult 
tasks  of  the  medical  adviser  who  fully  understands 
these  cases,  and  sees  the  true  meaning  of  these  cardiac 
symptoms,  to  convince  such  patients  that  their  trouble 
is  functional  purely,  and  that,  so  far  from  being  likely 
to  die  in  a  moment,  they  will  probably  Uve  all  the 
longer  for  their  heart  annoyances. 

The  heart  goes  up  or  down  through  reflex  irritation, 
from  any  one  or  all  of  the  great  centres  of  irritation — 
from  the  brain  through  emotion  of  any  kind,  from  the 
stomach  through  indigestion,  or  so-called  biliousness, 
from  any  part  of  the  genito-urinary  tract,  but  espec- 
ially from  the  prostatic  urethra. 

Now  what  is  true  of  the  heart  is  also  true  of  the 
whole  vascular  system,  though  less  demonstrably  and 
perceptibly.  Through  the  combined  action  of  the 
cerebro-spinal  and  vaso-motor  system  of  nerves  in  all 
their  complexities  and  involvements,  the  large  and 
minute  blood-vessels  everywhere  are  constantly  liable 
to  change  in  their  cahbre  through  reflex  irritation 
from  any  part  of  the  body.  This  is  the  philosophy  of 
the  passive  congestions  of  which  I  have  previously 
spoken,  which  may  take  place  in  the  brain,  in  the 
spine,  in  the  stomach,  in  the  genito-urinary  system,  or 
very  likely  in  the  heart  itself.  The  tone  of  the  vessels 
is  diminished  through  faulty  innervation;  hence  the 
explanation  of  the  statement  previously  made,  that 
in  pathology,  innervation  precedes  circulation — the 
nerves  control  the  arteries.  Anaemias  and  hyperae- 
mias,  congestions  and  the  opposite  states,  are  the  re- 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  153 

sultants  of  the  state  of  the  nerves  of  the  cerebro-spinal 
and  the  vaso  motor  systems. 

Not  only  such  phenomena  of  neurasthenia  as  blush- 
ing, pallor,  and  excessive  sweating,  local  or  general, 
are  thus  explained,  but  also  very  many  other  of  the 
prominent  symptoms  of  this  state. 

That  there  are  sweat  centres  in  the  nervous  system 
is  now  pretty  well  demonstrated;  and  it  is  not  improb- 
able that  there  is  a  secreto- motor  system,  or,  if  not, 
what  is  practically  the  same,  a  special  mode  of  action 
of  the  nerves  that  distinctly  preside  over  the  secretions. 
Admitting  the  existence  of  such  a  special  division  or 
mode  of  action  of  the  nervous  system,  the  symptoms 
of  excessive,  local  or  general  sweating  (palmar  hyperi- 
drosis,  etc.),  sudden  attacks  of  diarrhoea,  of  excessive 
flow  of  urine,  of  salivation,  of  weeping,  are  satisfac- 
torily and  in  a  most  interesting  way  explained. 

If  a  neurasthenic  patient  raises  his  hand  and  holds 
it  up  for  a  time,  the  veins  will  soon  empty;  if  he  drops 
that  hand,  in  a  moment  the  veins  become  turgid  and 
full,  as  in  an  old  person.  This  change  takes  place 
more  quickly,  the  alteration  is  more  sudden  and  vio- 
lent than  in  a  person  in  full  health,  and  is  explained 
by  want  of  tone  in  the  nerves  of  the  vessels  and  of  the 
heart.  If  we  could  look  into  the  brain  and  the  spinal 
cord,  and  the  stomach  and  prostate  gland,  we  should 
find,  no  doubt,  the  same  condition  there  as  is  seen  in 
the  han<ls  or  in  the  conjunctiva. 

To  call,  however,  this  local  and  transient  and  chang- 
ing hyperaernia  the  disease,  is  to  substitute  effects  for 
causes;  the  changes  of  circulation  are  results  of  de- 
fective innervation — passive  hyponumia  is  the  product 
of  neurasthenia.  A  want  of  recognition  of  this  su- 
preme fact  is  the  basis  of  an  enormous  amount  of  lit- 
erature of    cerebral  anosmia  and    hypenumia,   with 


154  NERVOUS  EXHAUSTION. 

which  our  works  on  nerve-diseases  abound,  and  which 
would  never  have  been  written  if  this  fact  had  been 
clearly  recognized. 

So  far  as  the  circulation  is  to  be  taken  into  account, 
it  is  probable,  judging  from  all  the  sources  of  evidence, 
deductive  and  inductive,  that  passive  congestion,  en- 
largement of  the  veins,  is  more  frequent  in  neuras- 
thenia than  any  other  condition  of  the  blood-vessels. 
While  there  are  fluctuations,  very  likely,  between 
anaemia  and  hyperaeraia,  yet,  stasis  of  blood  is  proba- 
bly the  condition  which  we  shall  most  likely  find, 
when  the  symptoms  are  at  their  worst,  if  not  at  other 
times.  All  our  knowledge  of  disease  points  to  this 
general  conclusion;  and  examinations  of  the  eye  while 
in  a  state  of  hyperaesthesia,  that  have  been  made  by 
experts  with  the  ophthalmoscope,  show  pretty  clearly 
that  such  is  the  pathological  state.  It  is  quite  true 
that  there  may  be  considerable  passive  hyperaemia, 
local  or  general,  without  any  local  or  general  disturb- 
ance; but  this  fact  is  not  inconsistent  ^vith  the  view 
that  passive  congestion  in  a  neurasthenic  part  or 
organ,  would  be  more  hkely  to  be  accompanied  with 
pain  and  irritation  than  the  same  amount  of  conges- 
tion in  a  healthy  person. 

The  probabilities,  therefore,  are  almost,  if  not  quite, 
convincing  that,  if  we  could  examine  the  spinal  cord 
with  its  membranes  during  an  attack  of  spinal  irrita- 
tion; or  the  ovaries  during  an  attack  of  ovarian  irrita- 
tion; or  of  the  prostatic  urethra  in  disorder  of  that 
part,  we  should  find  in  many  cases,  if  not  in  all,  or  in  a 
majority,  passive  congestion;  and  it  is  very  probable 
that,  if  we  could  study  these  parts  at  all  times  and  in 
all  stages  of  the  disease,  we  should  find  that  the  circu- 
lation would  vary  very  greatly.  But  if  we  should 
farther  infer  that  this  slight  circulatory  disturbance 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  155 

was  all  there  was  to  the  pathology,  we  should  make 
the  greatest  possible  mistake  in  reasoning. 

The  simple  condition  of  hypera3mia  is  not  necessarily 
pathological,  nor  does  it  in  a  healthy  person  cause  any 
unpleasant  symptoms;  but  when  a  person  is  in  a  neu- 
rasthenic state,  a  very  slight  disturbance  in  the  circula- 
tion, a  trifling  afflux  of  blood,  a  passive  venous  conges- 
tion that  can  only  be  seen  under  close  inspection,  may 
cause  distressing  symptoms.  The  ophthalmoscope 
shows  this  to  be  the  case  in  the  eye,  and  it  is  probably 
just  as  true  of  the  rest  of  the  body.  Dr.  Roosa,  in 
examining  one  of  my  neurasthenic  patients  who  had 
asthenopia,  remarked  to  me  that  he  saw  nothing  of 
any  account  in  the  patient's  symptoms,  which  had 
been  serious  and  long  standing,  except  a  slight  hyper- 
cemia  of  the  retina;  and  that  he  had  seen  still  gi'eat'er 
hyperaemia  without  any  abnormal  symptoms  what- 
ever. In  this  lies  the  whole  philosophy  of  this  subject: 
the  real  pathology  of  neurasthenia  is  not  in  the  circula- 
tion, but  in  the  innervation;  and  it  is  just  as  real  as 
though  it  were  seen  with  the  eye. 

Dr.  Salisbuiy,  of  Cleveland,  claims  to  be  able  to 
diagnosticate  a  seriously  exhausted  condition  of  the 
nervous  system  by  the  changed  appearance  of  the 
blood  coi-puscles;  his  theory  being  that  the  red  corpus- 
cles are  carriers  of  substances  that  feed  the  nerves; 
and  he  asserts,  that  when  these  corpuscles  are  not 
properly  laden  with  this  food  for  the  nerves,  as  in  the 
case  of  nerve  exhaustion  and  insanity,  the  corpuscles 
exhibit  changes  that  the  microscope  can  recognize; 
hence  an  addition  to  our  means  of  diagnosticating 
nerve  impoverishment.  Dr.  Heintzman,  of  New  York, 
claims  to  be  able  to  determine,  by  examination  of  the 
blood  under  the  microscope,  whether  the  constitution 
is  good  or  bad,  and  even  to  tell  whether  the  subject  is 


156  NERVOUS  EXHAUSTION. 

specially  exnausted  at  the  time  of  the  examination — 
as,  for  example,  after  a  sleepless  night. 

Both  of  these  claims  are  yet  on  their  trial  before  the 
piofession,  and  cannot  be  regarded  as  parts  of  science, 
until  they  have  been  indorsed  by  a  considerable  num- 
ber of  experts  of  admitted  authority,  and  also  made 
verifiable  by  others  who  shall  make  themselves  ex- 
perts; for  this  is  the  gauntlet  that  all  claims  must  pass 
before  they  are  permanently  received  into  the  fold  of 
science. 

If  either  or  both  of  these  claims,  or  some  similar 
claim,  shall  stand  the  cruel  test  of  time  and  expert 
skill,  we  shall  have  a  positive,  so  far  as  it  may  go, 
satisfactory  addition  to  our  means  of  studying  func- 
tional disorders  of  the  nervous  system,  and  a  very  in- 
teresting ocular  and  physical  proof  of  the  general  posi- 
tion that  I  have  here  taken. 

If  it  be  objected,  as  indeed  it  often  has  been — and 
by  those  for  whose  judgment  I  have  the  highest  re- 
spect— that  while  the  general  philosophy  and  analysis 
of  these  nerve  symptoms  are  found  and  "verifiable,  yet 
that  the  term  neurasthenia  is  faulty  in  that  it  indicates 
only  a  state  or  manifestation,  instead  of  a  limited 
pathological  lesion,  I  can  only  reply,  as  I  have  done 
from  the  first,  that  nearly  all  our  medical  terminology 
expresses  our  ignorance  more  than  our  knowledge; 
that  our  best  known  diseases,  as  epilepsy,  insanity, 
chorea,  hysteria,  hay  fever,  waiter's  cramp,  musician's 
cramp,  telegrapher's  cramp,  and  nearly  all  our  paral- 
ysis and  neuralgias,  receive  their  names  from  single 
and  striking  symptoms  or  suspected  factors  in  their 
causation,  which  terms  we  must  yet  retain,  despite  all 
our  actual  or  prospective  progress  in  neuropathology; 
and  there  is  no  objection  to  the  use  of  these  terms,  pro- 
vided we  understand  their  meaning;  indeed,  their  re- 


DIAGNOSIS  OF  NERVOUS  EXHAUSTION.  157 

tention  is  a  matter  of  necessity,  till  such  time  as  the 
minute  pathology  of  these  phenomena  shaU  be  un- 
veiled. Then  they  can  be  and  wiU  be  gradually  aban- 
doned. 

Functional  as  distinguished  from  Organic  Disease. 
— Throughout  this  work  I  have  used  the  words 
"functional"  and,  '"structural,"  in  their  ordinary 
senses,  without  any  desire  to  play  upon  them,  or  twist 
them  to  accord  with  any  theory.  These  old  terms  are 
justifiable.  Practically,  we  apply  the  term  stiTictural, 
or  organic,  to  those  diseases  where  the  pathology, 
whatever  it  may  be,  can  be  brought  under  the  direct 
observation  of  the  aided  or  unaided  senses. 

Functional  diseases,  on  the  other  hand,  are  those 
where  the  pathology,  whatever  it  may  be,  cannot  be 
brought  under  the  observation  of  even  the  best  aided 
senses.  What  the  microscope  can  see,  we  call  struc- 
tural— what  the  microscope  cannot  see,  we  call  func- 
tional. 

In  fmictional  nervous  disease,  the  pathology  is  nega- 
tive— a  deficiency  in  quantity  or  quality  of  the  normal 
constituents  of  the  nerve  substance.  In  organic  or 
structural  nerv^ous  disease  the  pathology  is  positive — 
an  addition  of  abnormal  substances  to  the  veins.  We 
can  more  easily  supply  what  is  wanting  in  the  nutri- 
tion of  the  veins  than  remove  what  is  organized  in  the 
vein  as  a  foi-eign  substance. 

In  the  chances  of  relief  and  cure  all  the  advantages 
are,  therefore,  of  necessity  on  the  side  of  functional 
disease.  It  is  because  neurasthenia  is  a  functional  dis- 
ease that  it  is,  under  right  management,  so  relievable. 

RecajiH nlnt io)i.  ~H\\v  leading  jjoints  of  the  patliology 
and  rationale  of  neurasthenia  may  bo  thus  ei)itomized: 

1.  Neurasthenia  is  a  chronic,  functional  disease  of 
the  nervous  system,  the  basis  of  which  is  impoverish- 


158  NERVOUS   EXHAUSTION. 

ment  of  nervous  force,  waste  of  nerve-tissue  in  excess 
of  repair;  hence  the  lack  of  inhibitory  or  controlhng 
power — physical  and  mental — the  feebleness  and  in- 
stability of  nerve  action,  and  the  excessive  sensitive- 
ness and  irritability,  local  and  general,  direct  and 
reflex.  The  fatigue  and  pain  that  temporarily  follow 
excessive  toil,  or  worry,  or  deprivation  of  food  or  rest 
are  symptoms  of  acute  neurasthenia,  from  which  the 
chronic  form  differs  only  in  permanence  and  degree. 
Nervousness  is  really  nerv^elessness. 

2.  The  varying  and  multitudinous  symptoms  that 
accompany  neurasthenia  are  largely  the  result  of  re- 
flex irritations  that  take  place,  not  only  through  the 
ordinary  motor  and  sensory  nerves,  but  through  the 
sympathetic  system  and  vaso-motor  nerves.  These 
reflex  irritations  may  arise  from  any  part  of  the  bod3^ 
and  may  be  transmitted  to  any  other  part:  but  the 
chief  centres  of  such  irritation  are  the  brain,  the  diges- 
tive system,  and  the  reproductive  system. 

3.  The  heart  and  blood-vessels,  through  their  abun- 
dant, complex,  and  sensitive  nerve-supply,  are  quick  to 
feel  any  such  reflex  irritation  from  any  source.  Thus 
the  local  and  general  blood-supplj^  of  the  body  is  liable 
to  fluctuation,  with  a  special  tendency  to  local  passive 
hyperaemia  or  venous  congestion.  In  the  eye,  this 
condition  can  be  inductively  demonstrated.  The  cir- 
culation is  thus  kept  constantly  unbalanced,  waves  of 
hyperaemia  pass  from  one  organ  to  another,  under  the 
influence  of  a  myriad  exciting  causes.  Thus  is  ex- 
plained the  inconstancy  and  correlation  of  the  symp- 
toms, the  caprice  with  which  they  come  and  go,  and 
the  substitution  of  one  symptom  for  another. 

4.  Innervation  precedes  circulation.  These  local  and 
varied  hyperaemias,  with  the  special  and  local  symp- 
toms to  which  they  give  rise,  are  not  strictly  diseases, 


DIAGNOSIS   OF  NERVOUS    EXHAUSTION.  159 

but  the  results  of  disease.     These  hyperaemias  are  the 
products  of  neurasthenia. 

5.  The  so-called  cerebral  irritation,  spinal  irritation, 
irritable  eye  [neurasthenic  asthenopia],  irritable  ear, 
instable  stomach  [nervous  dyspepsia],  irritable  heart, 
instable  uterus,  irritable  ovary,  and  irritable  j^rostate, 
are  but  special  local  manifestations  of  the  general  neu; 
rasthenic  state.  These  special  conditions  caimot  be 
scientifically  studied  or  treated  individually  or  sepa- 
rately; but  only  in  relation  to  each  other,  and  to  the 
trunk  of  which  they  are  the  branches. 

6.  Neurasthenia  may  exist  entirely  independent  of 
anaemia.  Its  subjects  are  often  exceptionally  physi- 
cally strong,  and  with  all  their  nervous  weakness  and 
pains,  capable  of  sev^ere  muscular  toil  and  endurance. 
It  may,  however,  be  comphcated  with  anaemia,  and 
also  mth  various  organic  diseases,  of  which  it  is  some- 
times the  result,  thougli  but  rarely  the  cause.  As  the 
blood  is  the  body  in  a  fluid  state,  conveying  the  mater- 
ials of  the  nervous  system  as  weU  as  of  other  tissues,  it 
is  probable  that  it  changes  in  its  constitution  with  the 
various  states  of  neurasthenia;  and  it  is  not  improba- 
ble that  such  changes,  in  the  corpuscles  at  least,  may  be 
in  some  way  brought  within  the  range  of  the  senses. 

Sucli,  in  substance,  was  the  philosophy  of  neuras- 
thenia tliat  I  taught  in  my  first  paper  on  the  subject, 
as  published  in  1SG9,  and  subsequently  re-published  as 
a  chapter  in  Beard  and  Rockwell's  "  Surgical  P]lectric- 
ity."  This  philosophy  lias  been  in  the  main  adopted 
and  advocated,  and  the  observations  and  reasonings 
that  led  to  it  confirmed  by  all  who,  since  that  time, 
have  conspicuously  written  upon  neurasthenia.  It 
would  seem,  therefore  to  have  passed  the  ordeal  of  a 
sufficient  number  of  experts  in  its  department  to  be 
admitted  among  the  accepted  facts  of  science. 


CHAPTER   IV. 

PKOGNOSIS   AND   SEQUENCES. 

A  QUESTION  which  to  the  sufferers  of  neurasthenia 
and  to  physicians  is  most  important  of  all — What  can 
be  done  to  reUeve  or  cure  these  cases  ?  What  are  their 
hopes  for  the  future  ? 

In  answer  it  may  be  said  that  the  majority  can  be 
reheved,  or  substantially  cured.  The  number  of  those 
of  whom  this  cannot  be  proved  must  be  very  Hmited 
indeed.  This  rehef  or  cure  cannot  be  obtained  in  a 
moment,  or  by  a  mere  prescription  or  suggestion;  but 
it  is  the  reward  only  of  a  proper  and  faithful  carrying 
out  of  the  modes  of  treatment  and  hygiene  that  have 
borne  the  test  of  time  and  experience. 

The  first  thing  required,  however,  is  to  know  what 
the  disease  is;  to  understand  it,  and  to  know  what  it 
is  not;  and  then,  as  a  proper  sequence,  to  obtain  a  just 
and  reasonable  idea  of  the  principles  and  methods  by 
which  it  is  to  be  treated. 

This  knowledge  is,  indeed,  one-half  of  the  cam- 
paign, and  for  want  of  it,  there  are  thousands  who 
pass  through  years  of  suffering,  apprehension,  and 
despair;  all  the  while  anticipating  or  fearing,  and,  in 
some  instances,  almost  hoping  that  some  incurable 
organic  disease  will  seize  hold  of  them  and  bear  them 
away. 

Recent  Progress  made  in  the  Treatment  of  Neuras- 
thenia and  allied  Affections. — There  is  probably  no 
department  of  therapeutics  in  which  greater  progress 


PROGNOSIS  AND  SEQUENCES.  161 

has  been  made  than  in  the  treatment  of  neurasthenia 
and  affections  allied  to  it,  during  the  last  fifteen  years. 
Indeed,  an  absolute  revolution  has  been  wrought,  both 
in  the  hygiene  and  medical  management  of  disorders 
of  this  class;  new  remedies,  new  modes  of  using  old 
remedies,  new  combinations  of  remedies,  new  doc- 
trines of  hygiene,  all  have  been  introduced  in  this  Hm- 
ited  time,  and  all  together  have  made  an  era  in  the 
therai)eutics  of  these  neuroses.  The  introduction  of 
local,  general,  and  central  electrization  alone  has  added 
a  new  continent  to  therapeutics;  while  the  bromides 
in  all  their  "arieties  and  combinations,  which  were  Ht- 
tle  or  not  at  all  known  fifteen  years  ago,  are  now  used 
by  the  ton  in  civilized  countries,  and  have  put  it  with- 
in our  power  to  relieve  and  cure,  where  formerly  we 
sliould  have  been  helpless. 

Relief  and  Recovery  of  Special  Symptoms. — Very  in- 
teresting, indeed,  it  is  to  note  the  rapidity  with  which 
certain,  even  very  long-standing  symi)toms  of  neuras- 
thenia are  relieved  at  the  beginning  of  a  course  of 
treatment.  Sleeplessness,  for  example,  one  of  the 
most  common  of  all  tlio  symptoms,  and  one  of  the 
most  distressing  to  patients,  is  sometimes  relieved  in  a 
few  days  after  treatment  is  begun,  and  that,  too,  with- 
out the  use  of  any  powerful  anodynes  or  narcotics. 
Likewise,  the  terrible  symptom,  mental  depression, 
wliicli  drives  some  of  these  cases  almost  to  suicide,  is 
in  some  instances  removed  instantly  by  a  full  consul- 
tation, wherein  they  receive  clear  and  just  informa- 
tion as  to  the  real  nature  of  the  malady  and  the  proba- 
bilities of  a  cure,  and  enter  with  courage  and  will  on  a 
line  of  treatment.  Some  who  have  nursed  and  wor- 
ried for  years  over  their  physical  sorrows,  are  quickly 
helped  by  a  free  unburdening  of  themselves  and  the 

obtaining  of  a  diagnosis  in  which  they  have  confidence. 
11 


162  NERVOUS  EXHAUSTION. 

The  special  symptom  of  morbid  fear,  in  its  numberless 
phases,  sometimes  recovers  of  itself,  and  sometimes  is 
the  very  last  of  all  the  symptoms  to  recover  under 
medicine  and  hygiene.  The  special  symptom  of  sick 
headache,  or  the  tendency  to  sick  headache,  can  usu- 
ally be  either  broken  up  or  greatly  relieved  in  a  few 
weeks  of  treatment;  hkewise  with  the  symptom  of 
spinal  irritation  and  cerebral  irritation.  The  test  and 
measure  of  improvement  is  not  so  much  the  relief  of 
any  one  symptom,  taken  by  itself  alone,  as  by  the 
average  of  all  the  symptoms.  In  some  instances,  cer- 
tain abnormal  sensations  may  grow  worse  at  first, 
while  others  grow  better,  and  on  the  average  there  is 
decided  improvement. 

In  some  cases  every  symptom  quickly  disappears, 
except  perhaps  one  which  remains  for  a  long  time  as 
a  perplexity  and  annoyance,  although  not  interfering 
with  the  daily  routine  of  active  life. 

Prognosis  depending  on  the  hereditary  character  of 
the  disease. — Neurasthenia,  like  everything  else  that 
belongs  to  the  constitution,  is  hereditary,  passing  down 
from  parents  to  children,  diffusing  itself  in  various 
ways  through  the  different  branches  and  ramifications 
of  families.  The  more  decided  and  positive  the  hered- 
itariness  of  any  case,  the  greater  the  difficulty  in  abso- 
lutely accomplishing  a  cure,  and  the  greater  the  likeH- 
hood'  of  a  partial  relapse  after  relief  has  been  obtained. 
Hereditary  neurasthenia  is  not,  however,  discouraging; 
it  yields,  and  sometimes  yields  quickly,  to  treatment; 
but  the  yielding  is  not  of  so  stable  a  character  as  in 
neurasthenia  which  is  accidental  or  that  appears  for 
the  first  time  in  individual  patients.  In  very  many 
cases,  neurasthenia  itself  is  not  hereditary,  but  the 
nervous  diathesis,  of  which  neurasthenia  is  an  evolu- 
tion, has  been  derived  from  the  parents  on  one  or  both 


PROGNOSIS  AND  SEQ'tenCES.  163 

sides;  but  in  this  malady,  as  in  consumption,  the 
hereditary  tendency  can  be,  and  is,  successfully  com- 
bated, although  the  contest  is  harder  and  longer  than 
for  those  whose  inheritance  is  perfect. 

Working  Order. — It  is  a  high  desideratum  to  put 
these  patients  into  working  order.  My  expectation 
and  ambition  is,  when  cases  of  this  class  come  under 
treatment,  to  so  manage  them  that  they  shall  be  able 
to  attend  to  those  duties  in  which  they  are  happy  and 
useful.  Persons  who  have  retired  from  active  employ- 
ment, or  who  have  been  kept  from  engaging  in  active 
and  responsible  toil  on  account  of  their  neurasthenia, 
are  encouraged  and  aided  to  look  forward  to  the  time 
when  they  shall  again  renew  their  labors.  This  ex- 
pectation is  itself  a  curative  force;  and  to  put  these 
cases  into  working  order  is  to  accomplish  a  great  work, 
which  they  well  appreciate,  and  it  is,  indeed,  practi- 
cally to  cure  them,  even  though  many  impleasant 
symi)toms  at  times  distress  them. 

One  of  the  pleasant  experiences  of  travel  is  the 
meeting  with  former  patients,  who  have  substantially 
recovered  from  their  nervous  exhaustion,  and  are  at 
work  in  their  various  occupations.  I  have  thus  had 
opportunity  to  watch  the  cases,  from  time  to  time,  for 
many  years,  and  have  had  a  chance  to  see  that  the 
recovery  is  permanent;  and  also,  to  know  that  they 
grow  stronger  and  more  enduring,  after  all  treatment 
is  susixinded.  Cases  that  have  been  distressingly 
hyi)Ochondriacal,  as  well  as  the  neurasthenic,  and  who 
have  given  up  all  hope  of  ever  enjoying  hfo  again,  I 
find  to  be  cheerful,  laborious,  and  hopeful. 

Sequences  of  Neurasthenin. — Neurasthenia  is  the 
door  which  opens  into  quite  a  large  number  of  diseases 
of  the  nervous  system.  It  does  not,  necessarily,  lead 
to  any  of  these;  it  may  never  go  beyond  itself;  but, 


164  NERVOUS  EXHAUSTION. 

when  neglected  or  treated  improperly,  it  may,  in  time, 
advance  to  any  one  of  quite  a  large  number  of  familiar 
maladies  of  the  nervous  system.  Some  of  these  mala- 
dies are  not  of  an  organic  or  stiTictural  character;  they 
are  functional  like  neurasthenia  itself;  but  they  are, 
oftentimes,  more  obstinate  than  simple  neurasthenia 
— not  so  disposed  to  yield  to  management.  Neuras- 
thenia may  go  on  for  years,  sometimes  for  many  years, 
before  it  reaches  any  of  these  diseases;  but  it  may  and 
does  reach  them,  and  becomes,  in  fact,  one  of  the 
most  frequent  of  their  immediate  causes. 

Insanity  {Melancholia). — One  of  the  most  familiar 
sequences  of  neurasthenia  is  insanity  itself,  especially 
in  the  form  known  as  melancholia.  Not  a  few  of 
the  cases  of  melancholia,  in  its  different  stages,  that 
enter  our  asylums  or  inebriate  homes,  have  passed 
through  a  long  stage  of  neurasthenia,  before  they  ar- 
rived at  the  condition  where  the  mind  is  really  and, 
perhaps,  permanently  disturbed.  The  change  from 
simple  neurasthenia  to  melancholia  is  sometimes  grad- 
ual, and  sometimes  quite  sudden.  In  some  instances, 
there  may  be  a  very  gradual  decline,  from  a  nervously 
exhausted  state  to  the  most  serious  stage  of  mental 
disorder.  Under  this  class  come  not  a  few  women— 
house-wives  who  are  over- worked  ; .  mothers,  worn  by 
repeated  child-bearing  and  prolonged  lactation,  com- 
plicated, perchance,  with  local  disorders,  such  as  lacer- 
ation, enlargment,  or  inflammation. 

Hysteria  and  Hystero-Epilepsy.— It  is  only  a  minor- 
ity of  the  cases  of  hysteria  and  hystero-epilepsy  that 
have  first  passed  through  the  stage  of  neurasthenia. 
Both  hysteria  and  hystero-epilepsy  may  arise  in  persons 
who  have  not  been  especially  nervously  exhausted, 
but  whose  mental  organization  is  weak  and  ill-trained, 
and  who,  consequently,  fall  into  the  symptoms  of 


PROGNOSIS  AND  SEQUENCES.  165 

these  disordei"S  through  needless  apprehension  or 
worry,  or,  perchance,  catch  them  through  psychical 
contagion.  Such  cases  of  hystero-epilepsy,  as  Charcot 
utilized  in  his  experiments  in  the  Salpetriere  hospital, 
Paris,  ^vith  metals  and  magnets,  are  not,  usually  or 
always,  of  a  neurasthenic  type;  they  are  simply  weak- 
minded,  mentally  untrained  girls,  who  can  usually  be 
affected  either  way.  Hysteria  and  hystero-epilepsy  of 
this  kind,  mental  epilepsy,  was  more  common  hundreds 
of  years  ago,  before  neurasthenia  was  thought  of. 

General  Neuralgia. — One  of  the  results  of  neglected 
neurasthenia  is  general  neuralgia — by  which  I  mean 
attacks  of  neuralgic  pains  flying  about  in  different 
parts  of  the  body,  in  distinction  from  fixed  and  local 
neuralgia— such,  for  example,  as  sciatica  and  tic  dou- 
loureux, which  may  occur  not  only  in  the  neurasthenic, 
but  in  persons  of  great  strength  and  vigor,  and  who 
are  not,  in  any  way,  anaemic  or  nervously  exhausted. 
The  neuralgia  of  the  neurasthenic  is  more  likely  to  take 
the  phase  of  chronic  flying  pains  in  the  lower  extrem- 
ities; or  in  the  upper  extremities;  or,  perchance,  in 
the  stomach  or  bowels,  in  the  eye,  or  in  the  pelvic  re- 
gions. 

Inebriety. — A  more  common,  indeed,  a  very  common, 
and  an  increasingly  common  sequence  of  neurasthenia 
is  inebriety.  Indeed, the  main  cause  of  the  increase  and 
frequency  of  the  disease,  inebriety,  in  this  country  and 
in  all  highly  civilized  countries,  is  the  increasing  nerv- 
ousness of  the  age.  When  a  man  becomes  prostrated 
by  exposure  to  heat — what  is  called  heat-prostration — 
lie  oftentimes  is  left  in  a  neurasthenic  state.  A  few 
moments'  exposure  of  this  kind  may  be  the  source  of 
neurasthenic  invalidism,  lasting,  it  may  be,  for  months 
or  years.  While  in  this  state,  an  iiresistible  desire  for 
drinking  alcoholic  liquors  may  take  possession,  and 


166  NERVOUS  EXHAUSTION. 

very  suddenly,  indeed,  of  one  who  never  before  had 
the  least  inclination  for  drink,  and  without  any  appar- 
ent cause,  he  may  become  an  inebriate;  an  attack  of 
inebriety  may  come  on  as  suddenly  as  an  attack  of 
neuralgia,  or  insomnia,  or  hay- fever,  and,  like  these, 
may  often  be  a  direct  sequence  of  neurasthenia  excited 
by  exposure  to  heat.  Neurasthenia  excited  by  any 
other  cause  may  have,  and  does  have,  just  this  effect; 
though  not,  usually,  with  such  suddemiess  or  violence. 
The  neurasthenic  state  developed,  as  it  is  so  often,  by 
the  shock  of  bereavement,  of  domestic  disappointments 
and  griefs,  anxiety  on  account  of  financial  troubles 
and  worries,  may  open  the  door  to  inebriety;  and,  so 
to  speak,  push  the  patient  in.  and  sometimes  shut  him 
up  beyond  remedy.  Phenomena  of  this  kind  occur  in 
those  who  have  never  been  accustomed  to  drinking — 
sometimes  in  those  who  have  been  total  abstainers  all 
their  lives,  or  who,  at  least,  have  never  been  excessive 
drinkers.  Quite  a  large  number  of  wealthy  citizens  of 
this  country,  merchants,  manufacturers,  speculators, 
and,  in  a  few  instances,  professional  men,  who  have 
acquired  their  means  by  constant  friction,  and  great 
and  excessive  drafts  on  the  nervous  system,  have  sons 
who  were  born  in  the  midst  of  this  pressure  and  toil, 
who  inherit  the  nervous  diathesis  and  tendency  to 
disease  of  the  nervous  system,  which  breaks  out  in 
the  form  of  inebriety. 

Meconism  {Opio-Mania). — This  form  of  excess  in  the 
use  of  narcotics  is  sometimes  a  sequel  of  neurasthenia. 
One  of  the  effects  of  opium  is  to  relieve,  for  the  time, 
the  depression— the  hopelessness,  worse  than  pain — 
from  which  neurasthenics  suffer.  It  is,  therefore,  a 
temptation  to  use  this  drug;  beginning,  of  course, 
with  smaU  doses,  and  increasing  until  the  servant  be- 
comes the  master — the  patient  a  slave.     In  some  cases 


PROGNOSIS  AND  SEQUENCES.  167 

there  is  an  alteration  of  opio- mania  with  inebriety; 
they  must  take  in  excess  one  of  those  two  poisons, 
alcohol  or  opium.  In  one  case  in  which  I  was  con- 
sulted, the  patient  stated,  positively,  that  it  was  ini- 
poesible  for  him  to  get  along  without  being  an  opium 
eater  or  an  inebriate;  that  it  made  little  difference 
which  he  took,  whiskey  or  opium,  either  one  or  the 
other  was  sufficient  for  him.  Not  all  cases  of  inebri- 
ety or  opium  eating  have  a  neurasthenic  origin,  but  a 
large  number  are  of  this  kind.  We  can  make  a  dif- 
ferential diagnosis  of  neurasthenic  inebriety  by  the 
symptoms  that  accompany  it.  Inebriates  of  this  kind 
always,  or  almost  always,  have  other  evidences  of  ex- 
haustion, such  as  insomnia,  headache,  nervousness, 
irritahifitv,  neuralgia,  and  the  hke:  and  inebriety  in 
these  cases  is  just  as  tmly  a  symptom  of  the  exhausted 
state  as  the  other  symptoms  accompanying  it,  and 
ought  to  be  so  regarded. 

Inebriety  and  opium  mania  of  this  kind  are  to  be 
treated  like  the  other  symptoms  of  neurasthenia,  that 
is,  by  strong  sedatives,  alternating  with  tonics;  and 
there  ai-e  many  of  these  cases,  at  least  a  considerable 
number,  that  can  be  treated  outside  of  an  asylum — at 
home — and  while  pursuing  their  regular  business.  I 
boliovo  in  inebriate  asylums  and  liave  been  for  years 
their  earnest  advocate  and  defender,  just  as  I  believe 
in  and  advocate  insane  asylums,  and  there  is  no  antag- 
onism between  th<Mn.  Tliere  are,  however,  a  large 
num])er  of  inebriates  that  can  be  successfully  treated 
outside  of  an  asylum,  just  as  there  are  some  cases  of 
melancliolia  and  other  phases  of  insanity  of  a  mild 
ty])e  tli;it  can  be  treated  successfully  by  a  physician 
without  sending  them  to  any  institution  wliatever, 
and,  indeed,  more  successfully  tban  in  any  institution, 
provided  they  have  sensible  friends  and   propei-  sur- 


168  NERVOUS  EXHAUSTION. 

roundings.  The  evil  of  opium-taking  in  nervous  ex- 
haustion is  a  growing  one;  constantly  I  am  called 
upon  to  treat  patients  who  have  added  the  morphine 
habit  to  their  weaknesses  and  pains. 

One  way  in  which  neurasthenia  induces  inebriety 
is,  that  it  causes,  sometimes,,  a  great  and  incredible 
tolerance  of  alcohol;  in  those  cases  they  can  bear  im- 
mense doses  without  feeling  any  effects,  good  or  bad — 
certainly  no  bad  effects.  Some  of  these  cases  are  i^ery 
interesting  indeed;  one  of  my  medical  patients  afflicted 
at  one  time  with  cerebrasthenia  (from  which  he  has 
now  recovered),  at  one  stage  of  the  disease,  when  he 
was  at  the  very  worst,  could  take  a  full  tumbler  of 
whiskey  and  not  feel  any  bad  effects,  although  he  was 
not  used  to  drinking  when  he  was  well.  On^  of  my 
hay  fever  patients,  in  whom,  as  is  sometimes  the  case, 
the  attacks  were  jDreceded  by  a  number  of  days  of  pro- 
found exhaustion,  though  he  was  not  accustomed  to 
drink  at  all,  tells  me  that  in  one  of  those  attacks  of 
exhaustion,  alcohoUc  liquor,  in  any  amount,  has  no 
effect  whatever. 

Disease  of  the  Reprodtictive  Organs. — Neurasthenia, 
long  neglected  or  badly  treated,  and,  sometimes,  in 
the  early  or  acute  stages,  is  a  common  excitant  of 
functional  and,  sometimes,  of  structural  maladies  of 
the  reproductive  organs.  In  males,  irritability  of  the 
prostate  gland  and  of  the  prostatic  urethra;  and  in 
females,  of  the  neck  of  the  uterus  and  of  the  ovaries, 
may  be  a  direct  result  of  general  neurasthenia.  It  is 
quite  true  that  diseases  of  these  parts  are,  themselves, 
excitants  of  neurasthenia;  but,  none  the  less,  is  it  true 
that  neurasthenia  excites  disease  in  them.  There  is, 
indeed,  a  constant  action  and  inter-action  between 
special  organs;  between  themselves  and  between 
special  organs  and  the  nervous  system  in  general;  so 


PROGNOSIS  AND  SEQUENCES.  169 

that,  in  individual  cases,  it  may  be  quite  hard  to  tell 
the  seat  of  the  primary  neurotic  implication.  A  want 
of  recognition  of  this  fact  is  the  basis  of  an  enormous 
quantity  of  non-expert  reasoning  on  this  subject, 
among  specialists  and  general  practitioners.  If  a 
female  presents  herself  to  a  g}Ti8ecologist  with  evi- 
dences of  inflammation  or  enlargement,  or  even  irrita- 
tion of  the  womb  or  ovaries,  and  has  associated  there- 
with a  number  of  symptoms  of  neurasthenia  as  I  have 
described  them,  the  natural  inference  is,  that  the  local 
disease  is  the  cause  of  the  general  disease — an  infer- 
ence sometimes  justified  by  facts  and  sometimes  not ; 
for  the  general  neurasthenia  is  as  likely  to  be  the  ex- 
citing cause  of  the  local,  as  is  the  local  trouble  to  be 
the  cause  of  the  general  neurasthenia.  The  worst  fail- 
ures of  skilled  gynaecologists  of  our  time  are  with  just 
this  class  of  cases;  and,  mainly,  because  they  treat 
them  locally,  without  treating  them  generally  or  con- 
stitutionally; or  if  they  do  treat  them  constitutionally, 
it  is  in  a  vague,  desultory,  half-hearted,  incidental, 
and  doubtful  manner,  that,  in  therapeutics,  is  always 
sure  to  fail  of  its  purpose.  While  cases  of  this  kind 
need,  oftentimes,  careful  local  treatment,  yet  such 
local  treatment,  however  judiciously  and  patiently  car- 
ried out,  is  wasted,  unless  it  be  accompanied  by  an 
equally  patiently  carried  out  constitutional  treatment. 
Exclusive  dependence  upon  either  local  or  general 
treatment  is  non-expertness,  one-sidedness,  halfness  of 
therapeutics;  for,  if  either  one  should  be  neglected,  it 
should  be,  in  some  cases  at  least,  the  local;  or,  at  least, 
the  local  should  be  made  incidental  or  secondary;  and  it 
is  creditable  to  one  of  the  best  known  of  our  gynaecol- 
ogists, Dr.  Goodell,  that  he  has  been  one  of  the  first, 
in  his  department,  to  recognize  this  fact,  and  to  illus- 
trate it  by  interesting  cases  accompanied  with  just  and 


170  NERVOUS   EXHAUSTION. 

verifiable  philosophizing  upon  this  subject.  Cases  of 
this  kind  sometimes  go  around  from  one  gynaecologist 
to  ^nother,  seeking  help  and  finding  none,  just  as  cases 
of  neurasthenic  asthenopia  go  around  from  one  oculist 
to  another,  getting  no  information  and  no  relief  be- 
yond this:  that  "there  is  nothing  the  matter  with 
them; "  which  is  equivalent  to  saying,  that  the  oph- 
thalmoscope can  reveal  nothing,  and  what  the  oph- 
thalmoscope cannot  reveal,  does  not  exist. 

My  own  habit  in  cases  of  this  kind  is,  to  obtain  the 
co-operation  of  practical  gynaecologists  and  oculists, 
and  I  have,  oftentimes,  thereby  secured  results  which 
no  one  department  alone  could  have  achieved. 

Hay  Fever. — One  very  interesting  sequel  of  neuras- 
thenia is  hay  fever,  which,  philosophically  analyzed, 
is  simply  a  nervous  idiosyncrasy,  usually  against  some 
one  or  many  external  irritants,  of  which  pollen,  sun- 
light, dust,  heat,  foul  air,  smoke,  and  various  fruits 
and  flowers  are  the  most  familiar.  But  these  external 
irritants,  any  one  of  them,  or  all  combined,  can  no 
more  excite  hay  fever  than  they  can  excite  small-pox 
or  leprosy,  unless  they  strike  on  a  nervous  system 
predisposed;  and  one  of  the  most  important,  indeed 
the  most  important,  element  in  the  predisposition  is 
nervousness,  though  not  always  going  on  to  neuras- 
thenia. 

While  many  hay-fever  sufferers  are  apparently  well 
and  hardy,  yet  in  all  there  is  a  neurotic  element,  if  we 
can  trace  it,  and  in  a  large  number  of  instances  this 
neurotic  elemeat  is  visible  in  many  ways— hay  fever 
being  only  one  of  many  symptoms,  and  not  always, 
by  any  means,  the  most  serious.  This  very  year,  one 
of  my  patients  who  is  profoundly  neurasthenic,  has 
made  an  addition  to  his  catalogue  of  symptoms,  by  an 
attack  of  the  later  form  of  hay  fever.     In  countries 


PROGNOSIS  AND  SEQUENCES.  171 

where  neurasthenia  is  rare,  hay  fever  is  rare,  and  vice 
versa;  they  rise  and  fall  together. 

Writer'' s  Cramp. — Writer's  cramp  is  a  disease  which 
is  characterized  by  a  group  of  from  fifteen  to  twenty 
symptoms;  the  cramp  beiyg  one  of  the  group  only, 
not  always  present  in  all  the  cases. 

There  are  several  types  of  this  disease.  In  quite  a 
number  of  cases  there  is  no  neurasthenia;  there  is  not 
even  a  marked  nervous  diathesis.  There  is  only  a 
local  weakness  of  the  nerves  and  muscles  connected 
with  the  act  of  wi-iting;  there  is,  also,  a  form  of  this 
disease  to  which  the  term  neurasthenic  writer's  cramp 
might  be  justly  a.pplied;  and  this  form  occurs  in  persons 
who  are  of  a  nervous  constitution,  who  are  nervously 
exhausted,  and  who  descend  into  the  symptoms  of 
writer's  cramp  through  the  other  symptoms  of  the 
neurasthenic  state.  Patients  of  this  kind  find  that  in 
writing  they  are  troubled  with  pain,  aching,  heaviness, 
fatigue,  tiredness  of  the  arm,  or,  in  some  cases,  a 
stiffness  that  suggests  rheumatism— and  they  are 
sometimes  so  nervous  that  they  cannot  write  at  all 
continuously,  without  suffering  from  a  nervousness 
which,  without  pain,  compels  them  to  stop. 

WHiilo  this  chai)ter  is  in  i)reparation,  I  have  received 
a  letter  from  a  neurasthenic  patient,  the  handwriting 
of  which  is  so  different  from  that  of  other  letters 
wliich  I  have  received  from  him,  that  I  did  not  recog- 
nize it.  In  this  letter  he  tells  me  that  quite  lately  he 
lias  been  troubled  with  this  difficulty  of  writing— a 
nervous  symptom  of  which,  before,  he  knew  nothing, 
although  he  had  not  been  well  for  years.  The  letter 
is  written  in  better  style,  he  tells  me,  than  most  of  his 
letters  of  late;  yet  there  are  many  mistakes  in  it,  and 
1  should  sui)pose  it  came  from  a  regular  writer's  cramp 
patient.    This  i)atieut  soon  recovered  from  tliis  attack. 


1Y2  NERVOUS  EXHAUSTION. 

It  is  a  satisfaction  that  writer's  cramp  of  this  vari- 
ety (the  neurasthenic)  gives  way  to  treatment  more 
readily  than  any  other  form;  the  diagnosis  is  far  more 
hopeful,  and  in  many  cases  patients  get  well  them- 
selves— which  is  never  the  case  with  the  severe  form 
of  writer's  cramp.  I  have  seen  and  treated  quite  a 
number  of  cases  of  neurasthenic  writer's  cramp  where 
the  recovery  has  been  absolute. 

Trance. — That  morbid  state  of  the  nervous  system 
which  we  call  trance,  but  which  is  popularly  known 
as  hypnotism,  somnambulism,  catalepsy,  all  being 
special  varieties  of  the  special  generic  condition  trance, 
is  one  of  the  interesting,  though,  perhaps,  not  most 
frequent,  or  the  most  serious  of  the  sequels  of  neuras- 
thenia. 

Neurasthenia  is  not,  by  any  means,  the  most  com- 
mon of  the  exciting  causes  of  this  state.  In  the  middle 
ages,  among  wild,  savage,  and  semi-barbarous  races, 
trance  existed,  and  has  spread  as  a  mental  contagion, 
even  among  persons  who  have  great  streagth  of  con- 
stitution, or  at  least  who  have  but  very  little  of  the 
nerve  element  in  them. 

Trance  of  this  variety,  in  its  psychical  form,  is  found 
to-day  among  certain  classes  of  the  people;  but  the 
majority  of  the  cases  of  trance,  among  our  better 
classes,  are  those  who  have  entered  that  state  through 
the  doors  of  neurasthenia.  Our  so-called  starvhig 
girls,  with  their  ecstasies  and  visions,  are  oftentimes 
neurasthenic  for  years,  before  they  develop  trance 
phenomena. 

Paralysis  and  Organic  Disease  of  the  Spinal  Cord. 
— Temporary  paralysis,  or,  at  least,  paralyses  that  are 
rehevable  and  curable  by  treatment,  are  quite  common 
in  the  course  of  neurasthenia,  and  they  pass,  often- 
times, by  the  name  of  hysterical  paralysis,  which, 


PROGNOSIS  AND  SEQUENCES.  173 

when  they  are  accompanied  by  the  positive  symptoms 
of  hysteria,  is  entirely  correct.  Bat  one  may  have 
true  neurasthenic  paralysis  without  any  symptoms  of 
hysteria  proper  preceding  or  accompanying  it.  Paral- 
ysis of  this  kind  may  affect  the  larynx,  causing  apho- 
nia, or  the  neck  of  the  bladder,  causing  retention  or 
incontinence;  or  any  one  of  the  upper  or  lower  ex- 
tremities. 

Paralyses  of  this  kind  may  sometimes  go  away  as 
soon  as  they  come,  and  sometimes  they  need  special 
and  prolonged  treatment.  But  they  differ  from  the 
stiTictural  paralyses,  in  that  they  do  get  well,  and  get 
well  perfectly,  sometimes. 

The  belief  which  some  have  held,  which  some  hold 
now,  in  relation  to  which  many  of  the  best  physicians 
of  our  time  are  in  doubt  and  fear,  that  neurasthenic 
spnptoms  are  the  predecessors  of  severe  and  incurable 
conditions  of  the  spinal  cord,  such  as  ataxia,  muscular 
atrophy,  spinal  meningitis  and  the  like,  are  not  in  har- 
mony with  the  facts,  and  will  be  lield  by  no  one  who 
unites  both  the  power  and  the  opportunity  for  observ- 
ing large  numbers  of  cases  tlirougli  many  years. 

Many  of  the  symptoms  of  neurasthenia  resemble  so 
nearly  the  symptoms  of  incipient,  and  even  the  final 
symptoms  of  sclerosis,  that  to  distinguish  them  is  very 
hard  indeed;  and  yet,  close  as  their  resemblance  is, 
tliere  is,  pathologically,  a  gulf,  wide  as  the  Atlantic, 
between  them.  I  do  not  deny  that,  in  occasional  in- 
stances, neurasthenia  negle(;ted,  exasi)erated  by  bad 
hygiene  or  by  bad  treatment,  may  be  the  ])recursor  of 
sclerosis,  or,  at  least,  of  permanent,  fixed  congestion  of 
the  cord  or  of  its  menil)ranes — just  as  it  is  the  ])ossiblo 
precui*sor  of  certain  fcjrnis  of  insanity — but  it  is  not 
the  rule  that  it  should  lead  to  these  conditions,  any 
more  than  it  is  the  rule  that  it  should  lead  to  insanity. 


174  NERVOUS  EXHAUSTION. 

Neurasthenia  has  symptoms  enough  of  itself,  and  is 
bad  enough  and  distressing  enough,  without  adding  to 
it  that  it  is  an  early  syniptom  of  structural  disease. 

Certain  Stages  of  Brighfs  Disease  (Albimiinuria). 
— Neurasthenia  appears,  in  some  cases,  to  prepare  the 
way  for  those  varied  congestions  and  inflammations  of 
the  kidneys,  to  which,  when  they  have  reached  a  cer- 
tain stage,  the  vague  term,  Bright's  disease,  is  applied. 
This  term,  Bright 's  disease,  is  the  one  in  use  to  include 
a  variety  of  morbid  conditions  of  the  kidney;  but  the 
generic  term,  congestion,  is,  without  doubt,  the  con- 
dition through  which  the  kidney  passes. 

Neurasthenia,  by  the  bad  nutrition  with  which  it  is 
connected,  would,  itself,  keep  the  circulation  in  a  state 
of  fluctuation  and  uncertainty,  and  prepare  the  way 
for  congestion  of  the  internal  organs;  especially  on 
exposure  to  cold  after  over-exertion. 

These  congestions  may  be,  at  first,  of  a  temporary 
character  only,  and  may  disappear  as  suddenly  as  they 
came.  But  in  some  cases  they  become  chronic,  and 
the  kidneys  assume  a  state  where  an  examination  of 
the  urine  shows  both  albumen  and  casts.  I  have  seen 
quite  a  number  of  cases  of  what  Ave  call  Bright's  dis  • 
ease  of  the  kidnej^,  as  judged  by  the  presence  of  albu- 
men and  casts,  that  seemed  to  have  followed  a  pro- 
longed neurasthenic  condition. 

It  is  a  pleasing  and  most  interesting  fact  that  these 
neurasthenic  forms  of  kidney  disease  are  amenable  to 
proper  treatment.  A  number  of  cases  that  I  have 
treated  gave  all  the  sj^mptoms  of  this  condition  under 
the  microscope,  and  apparently  recovered;  and  so  far 
as  can  be  seen,  the  recovery  is  permanent;  and  it  ap- 
pears, also,  to  be  the  direct  result  of  the  treatment 
used,  and  not  a  mere  coincidence. 

I  do  ngt  use,  for  these  cases,  the  internal  routine 


PROGNOSIS  AND  SEQUENCES.  175 

treatment  of  Briglit's  disease — for  the  very  good  rea- 
son that  I  liave  never  seen  any  very  good  results  from 
it — and  many  of  these  cases  had  tried  it  long  before  I 
had  seen  them.  I  treated  them  by  general  faradiza- 
tion and  galvanization,  by  counter  irritation  over  the 
kidneys,  persistently  kept  up,  and  by  the  administra- 
tion of  vegetable  tonics— very  much,  indeed,  as  I  treat 
the  neurasthenic  condition  itself,  when  it  attacks  the 
spinal  cord  or  the  brain. 

Tlie  effect  of  this  treatment,  in  some  cases,  is  seen  in 
the  urine,  very  speedily,  after  the  treatment  is  begun. 

A  case  of  tliat  kind,  that  was  utterly  given  up,  I 
lately  treated  with  the  best  results;  if  this  patient 
were  to  die  of  the  disease  of  the  kidneys,  nevertheless, 
the  improvement  she  has  made  under  the  treatment 
is  a  reality.  Even  in  the  later  (the  incurable)  stages 
of  Briglit's  disease,  after  dropsy  has  appeared,  I  have 
seen  most  pleasant,  though  not  so  tliorough,  results 
from  this  plan  of  treatment. 

It  is  my  conviction,  from  the  study  of  quite  a  num- 
ber of  these  cases,  and  a  careful  watch  over  them  after 
the  treatment  has  been  discontinued,  that  for  certain 
forms  of  Briglit's  disease  with  albumen  and  casts  in 
the  urine,  even  in  considerable  quantity,  and  witli  the 
debility  that  accompanies  such  conditions,  there  can 
be  relief,  nnd,  so  far  as  can  be  seen,  a  permanent  cure 
— not  by  tlie  old  plan  of  treatment,  l)ut  by  the  new — 
that  is,  by  proper  external  ai)i)li('ations  in  the  neigli- 
borhood  of  the  kidneys,  and  by  proper  sedatives  and 
tonics  int(;rnally.' 

'  For  more  detailod  discussion  of  eoino  of  the  questions  raised 
in  this  rliaptor.  tlu>  rca<l»'r  is  referred  to  my  niono^jfraph  on  "A 
New  Theory  of  Trance  (Tht*  Scientilic  I<a.ses  of  Dehisions),"  to 
several  pajters  by  J)r.  (Votliers  and  by  myself,  in  different  issues 
of  the  QiKirtvrlij  Journal  of  InebriHji,  and  to  an  abstract  of  my 
essiiy  read  before  The  Hritish  Me«lical  Association,  Au^just,  1879, 
as  pubhslu'd  in  the  British  Jliih'rtt I  Journal,  Aug.  23d,  1879. 


CHAPTER  V. 

TEEATMENT  AND   HYGIENE   OF  NEEVOUS 
EXHAUSTION. 

The  general  principles  by  which  we  are  to  be  guided 
in  the  treatment  of  neurasthenia  and  allied  disorders, 
may  be  condensed  in  the  following  aphorisms: 

1.  The  treatment  should  be  constitutional,  with 
special  attention  to  local  manifestations,  whenever 
they  become  severe.  To  devote  the  whole  attention 
to  special  and  local  phases;  as  spinal  irritation,  cere- 
bral irritation,  cerebral  hyj^eraemia,  asthenopia,  oxal- 
uria,  insomnia,  or  nervous  dyspepsia  is  unphilosophi- 
cal  and  can  never  be  successful. 

2.  Dependence  should  be  placed  not  on  any  one 
exclusive  mode  of  treatment,  but  rather  on  a  combi- 
nation of  various  methods,  local  and  general. 

3.  The  treatment  should  be  occasionally  changed, 
according  to  the  needs  of  the  patient. 

It  is  not  possible  to  set  the  rudder,  so  that  a  ship 
may  steer  straight  across  the  Atlantic;  it  must  be 
watched  each  moment  and  shifted  with  the  winds  and 
currents;  it  is  usually  impossible  by  a  single  prescrip- 
tion to  steer  a  neurasthenic  sufferer  over  the  long 
voyage  to  health.  I  rarely  allow  a  patient  to  take  any 
one  important  prescription  for  a  long  time  without 
either  seeing  them  or  hearing  from  them. 

Individual  idiosyncrasies  must  be  religiously  re- 
spected, and  when  we  find  one  cannot  bear  any  one 
remedy  or  mode  of  treatment,  we  can  fall  back  on 
other  remedies. 


HYGIENE  OF  NERVOUS  EXHAUSTION.  177 

Each  case  of  neurasthenia  is  a  study  of  itself.  No 
tivo  cases  are  alike  in  all  details.  If  two  cases  are 
treated  x)recisely  alike  in  all  the  details  from  beginning 
to  end,  it  is  jirobable  that  one  of  them  is  treated  lurong. 

4.  The  treatment  should  sometimes  and  by  intervals 
be  entirely  withdrawn.  Suspending  treatment  has  a 
positive  effect  upon  the  system.  Oftentimes  it  makes 
a  direct  impression,  which  may  be  better  than  contin- 
uous treatment.  A  friend  of  mine,  formerly  a  sea 
captain,  states  that  when  sleeping  in  his  cabin  at 
night,  if  the  sentinel  walking  the  deck  above  him 
stopped,  it  would  always  wake  him.  The  sudden  sen- 
sation of  nervous  activity,  like  a  jar  upon  the  nerves, 
aroused  him  from  his  slumber.  I  find  that  patients 
sometimes  do  better — make  more  decided  progress — 
in  these  intervals  of  treatment  than  while  the  most 
active  measures  are  being  used.  Patients  sometimes 
imagine  this  to  be  a  proof  of  the  valuelessness  of  the 
medicines;  but  it  is  in  reality  a  proof  of  their  power. 
It  has  been  said  that  success  in  life  depends  largely 
upon  knowing  just  where  to  stop.  In  the  practice  of 
medicine,  this  maxim  is  certainly  sound;  and  to  know 
where  to  stop,  to  let  up,  to  modify  the  treatment,  is 
one  of  the  best  tests  of  medical  skill. 

When  patients  are  a  long  time  under  care,  I  fre- 
quently have  them  take  a  sedative  prescription  or 
mode  of  treatment  one  week,  a  tonic  the  second  week; 
and  the  third  week  to  do  nothing  whatever. 

This  method  has  the  recommendation  of  safety,  in 
case  anything  in  the  treatment  should  meet  an  idio- 
syncrasy ;  and  it  also  lessens  the  risk  of  irritating  the 
stomach.  One  of  very  many  evils  of  domestic  and 
self-treatment  of  these  cases  is  the  tendency  to  overdo 
whatever  medication  is  employed. 

5.  Medical  treatment,  to  be  surely  effective,  must  be 

13 


178  NERVOUS   EXHAUSTION. 

combined  with  hygienic  treatment.  In  correct  analy- 
sis, hygiene  is  therapeutics,  the  distinctions  we  are 
wont  to  draw  between  them  being  purely  arbitrary. 
In  some  cases,  particularly  in  cerebrasthenia  (brain 
exhaustion),  vigorous  out-door  exercise  is  required, 
and  the  more,  within  reasonable  Hmits,  the  better;  in 
other  cases,  only  very  moderate  exercise  should  be 
allowed;  in  other  cases,  particularly  in  the  severe 
myelasthenia  or  exhaustion  of  the  cord,  in  women, 
absolute  rest  in  bed,  in  quiet,  if  not  darkened  rooms, 
is  needed,  if  we  would  get  in  the  shortest  possible  time 
the  best  results.  The  practical  mistake,  so  often 
made,  is  in  treating  all  these  classes  in  the  same  way, 
shutting  up  those  who  need  exercise,  and  exhorting 
those  to  work  and  travel  who  should  be  kept  in  bed. 

Digestive  Hygiene. — In  diet,  also,  aU  cannot  be 
treated  alike;  the  reaction  against  the  starvation  theo- 
ries of  the  last  century  has  induced  a  return  to  the 
habit  of  over-feeding;  hence,  some  need  to  be  cau- 
tioned in  this  regard,  while  others  must  be  coaxed  and 
tempted  to  eat  more  than  has  been  their  custom. 
Abstaining  from  starch  and  sugars,  or  using  these 
substances  but  moderately,  and  in  their  place  making 
as  free  use  as  the  digestive  organs  will  allow  of  fats, 
oils,  as  fish,  oysters,  butter  and  milk,  is  a  potent  ad- 
junct to  the  treatment. 

One  of  the  great  wants  of  the  day  is  an  increase  of 
fat  in  the  food;  and  fat  in  such  a  form  that  it  can  be 
assimilated  without  injuring  seriously  the  digestive 
apparatus. 

Our  fathers  could  eat  pork  and  digest  it,  and  thus 
they  obtained  in  their  daily  meals  aU  the  fat  the  sys- 
tem needed — sometimes,  perhaps,  in  excess;  but,  we 
cannot  digest  pork  as  they  could,  and,  consequently, 
we  are  suffering  in  all  directions  for  want  of  fat. 


HYGIENE  OP  NERVOUS  EXHAUSTION.  1Y9 

This  want,  the  use  of  the  oil  emulsions,  if  properly 
prepared,  in  a  certain  degi'ee  suppUes;  but  there  are 
some  stomachs  that  caanot  bear  even  these  emulsions, 
and  tliey  are  not  to  be  recommended  for  them,  mitil 
the  system  is  first  strengthened. 

Patients  are  apt  to  go  from  the  extreme  of  under- 
feeding to  the  extreme  of  overfeeding.  I  see  both 
forms  of  error  illustrated  in  my  cases. 

One  young  man  Avho  had  any  number  of  neuras- 
thenic symptoms,  but  who  was  accustomed  to  live 
freely  at  the  hotels  in  this  city,  found  that  nearly  all 
his  symptoms  left  him  when  he  reduced  the  quantity 
of  his  food  one-half.  If  he  had  been  taking  some 
medicine  for  his  disease,  at  that  time,  he  would  have 
supposed  that  a  brilliant  result  had  been  obtained  by 
it.  On  the  other  hand,  a  young  man  who  consulted 
me  during  the  past  year,  happened  to  say  to  me  that 
he  was  living  mostly  on  oatmeal,  eating  but  very  Ut- 
tle,  as  his  stomach  was  exceedingly  delicate.  He  was 
thin,  anaemic,  as  well  as  neurasthenic,  and  very  nmch 
depressed.  I  told  him  he  was  starving  himself.  A 
few  weeks  afterwards,  when  he  called  u}>on  me,  he 
was  very  much  increased  in  flesh,  and  better  in  his 
health.  He  said  that  my  suggestion  that  he  was 
starving  himself  made  an  imjiression  upon  his  mind; 
that  he  had  reformed  his  habits,  and  had  been  blessed 
accordingly. 

Ev(>n  when  there  is  severe  nervous  dyspepsia,  it  is  a 
mistake  to  be  over  rigid  in  the  diet;  starvation  of  the 
body  ijicreases  the  very  weakness  of  the  stomach 
itself,  and  thus  makes  the  indigestion  woi*se,  for  the 
stomach  itself  needs  nourishment. 

Jicc/df  Alimentatiou. — In  cases  where  the  stomach 
is  very  weak  and  oxhnustion  profomid,  it  is  well  to 
nourish  the  patient  through  the  rectum.     This  can  be 


180  NERVOUS  EXHAUSTION. 

done  by  the  injection  of  defibrinated  blood,  or  by  milk, 
or  the  juice  of  beef.  The  evidence  that  patjents  can 
be  nourished  for  weeks  in  this  way,  and  gain  strength 
thereby,  seems  to  be  A^ery  satisfactory  indeed. 

In  some  cases  of  chronic  nervous  disturbance,  it  is 
well  to  try  for  a  limited  time  an  exclusively  vegetable 
and  fish  diet.  It  is  the  belief  of  certain  English  phy- 
sicians that  vegetable  food  produces  more  stable  com- 
pounds than  meat;  a  vegetable  diet  has  been  tried  in 
epilej)sy,  in  the  hospitals,  with  a  certain  degree  of 
success.  All  the  functional  nervous  diseases  of  which 
I  am  here  speaking  are  characterized  by  instability  of 
nerve-force,  and  if  there  be  anything  in  this  theory, 
might  well  be  treated  in  accordance  with  it.  The  re- 
turn to  mixed  diet  should  be  gradual;  at  first  for  one 
meal  a  day,  or  three  times  a  week.  Even  if  the  chem- 
ical theory  of  the  greater  stability  of  the  compounds 
made  by  vegetable  food  be  unsound,  yet  it  may  be 
claimed,  with  plausibility  at  lea^t,  that  a  most  power- 
ful impression,  such  as  is  involved  in  a  sudden  change 
of  diet,  might,  in  some  cases,  do  good. 

Milh  Diet. —  A  diet  exclusively  or  largely  of  milk 
is  sometimes  invaluable  in  bed -ridden  cases.  For  dys- 
pepsia it  may  be  one  of  the  best  prescriptions.  But 
there  are  temperaments  that  will  not  bear  it. 

Very  frequent  feeding — small  quantities  taken  at  a 
time — has  been  suggested  by  Brown  Sequard;  and  in 
cases  where  debility  of  the  stomach  is  found,  it  is  of 
service  to  take  this  method.  Any  kind  of  light  food 
may  be  used  in  this  frequent  feeding,  and  the  meals 
may  be  all  the  way  from  half  an  hour  to  an  hour  or 
two  hours  apart;  and  the  meals  be  increased  in  fre- 
quency, as  the  tone  of  the  stomach  will  admit.  This 
method  of  dieting  is  worthy  of  trial  in  cases  where 
confinement  in  bed  is  necessary  for  a  time,  and  where 


HYGIENE   OF   NERVOUS  EXHAUSTION.  181 

debility  is  veiy  great,  and  where  food  of  almost  any 
quantity  is  liable  to  irritate.  In  any  especially  severe 
form  of  nervous  dyspepsia,  when  the  stomach  always 
feels  worse  when  it  is  empty,  feeding  frequently — 
never  overloading  the  digestive  tract — may  be  tried. 
The  English  and  Germans,  as  a  nile,  eat  of  tener  than 
the  Americans. 

The  class  of  nei'vous  invalids — who  can  moderately 
exercise  and  keep  on  with  their  business,  at  the  same 
time  taking  tonic  treatment — also  need  much  watch- 
ing in  regard  to  what  they  do;  for  their  temptation  is 
to  overdo  everything.  The  rule  I  generally  give  is,  in 
all  their  exercise  to  stop  short  of  much  fatigue;  if  they 
get  tired  out,  they  have  probably  done  too  much; 
there  should  always  be  force  in  reserve.  Many  such 
persons  are  advised  by  friends  and  by  physicians  to 
work  with  all  their  might — hoe  corn,  Hft  heavy 
weights,  or  take  fearful  tramps,  which  is  much  like 
advising  a  bankrupt  to  Uve  extravagantly. 

Rest  Cure  vs.  Wor-k  Cure. — There  is  a  time  for  rest, 
and  there  is  a  time  for  work,  in  the  treatment  of 
nervous  disease.  About  a  month  ago,  a  patient  with 
ataxy  came  to  me  from  a  distant  city  in  the  West.  I 
said  to  him,  "  You  have  left  behind  you  a  better  doc- 
tor than  you  can  find  here."  He  asked,  "Whom?" 
I  said,  *'  Rest .' "  I  prescribed  it  for  him  and  put  him 
to  bed.  He  had  ])eon  accustomed  to  take  excessive 
exercise — at  least,  far  more  than  was  good.  The  next 
day,  another  gentleman  came,  also  from  a  distant  city, 
witli  tlie  history  of  a  certain  form  of  cerel)rasthenia — 
brain  exliaustion — without  any  myelastlienia,  or  spinal 
exhaustion — and  of  a  type  that  would  he  bonefited, 
rather  than  injured,  by  a  degree  of  mental  and  i)liysi- 
cal  activity.  He  had  felt  dislieartened,  and  thought 
there  was  httle  for  him  to  do  in  this  world.     He  was 


182  KERYOUS  EXHAUSTION. 

of  about  middle  life,  and  I  told  him  that  he  probably 
was  no  more  than  "  half-way  home, "  and  so  far  as 
the  disease  was  concei-ned.  he  might  Uve  and  be  active 
for  thirty  or  forty  years  longer.  When  he  returned, 
I  said  to  him,  "  You  have  come  a  long  distance  to  con- 
sult me,  but  you  have  left  at  home  a  better  physician 
than  you  can  get  here. "  He  asked,  "  \Vlio  is  it  ? "  I 
said,  "  Work;  work  I  prescribe  for  jo\i.  Take  that 
in  connection  with  all  your  medicine,  and  you  will  re- 
cover." These  two  cases  make  clear  the  opposite 
methods  of  treatment.  Then  also  frequent  change  of 
work  is  to  be  advised:  steady  activity,  but  not  in  any 
single  direction,  resting  by  alternation  of  work.  The 
hygiene  of  nervous  diseases  has  three  gospels— rest, 
work,  and  change  of  work. 

Rest  and  Isolation. — The  treatment  of  certain  cases 
of  nervous  diseases,  functional  and  organic,  by  putting 
the  patient  in  bed  and  enforcing  inactivity  for  a  hmited 
period,  is  sometimes  one  of  the  best  possible  means  of 
rehef  and  cure.  One  of  the  great  benefits  that  an 
attack  of  acute  disease,  as  typhoid  fever,  confers  on  a 
neurasthenic  patient,  is  the  absolute  rest  it  compels. 
Improvement  in  flesh  is  very  soon  seen,  and  in  time 
there  comes  also  improvement  in  strength,  which, 
when  carefully  husbanded  and  directed,  may  become 
a  permanent  addition  to  the  patient's  stock  of  vitality. 
As  tliis  method  of  treatment  was  formerly  used,  evil 
as  well  as  good  might  be  accomphshed,  for  the  con- 
finement in  dark  rooms,  the  low  diet,  the  abstraction 
of  blood  with  which  this  rest  ti-eatment  was  often 
associated,  tended  to  pull  down  rather  than  build  up 
the  constitution,  and  in  the  times  of  our  fathers, 
cases  of  dyspepsia  even  were  managed  in  this  way 
with  the  effect  of  weakening  the  already  weakened 
frame.      But  rest  combined  with  proper  nourishment, 


HYGIENE   OF   NERVOUS  EXHAUSTION.  183 

passive  exercise,  and  the  judicious  and  varied  employ- 
ment of  sedatives  and  tonics,  especially  of  electricity, 
in  the  modes  of  general  faradization  and  central  gal- 
vanization, is,  in  many  cases  of  myelasthenia,  exhaus- 
tion of  the  spine,  superior  to  any  other  plan  of  treat- 
ment, since  it  really  includes  all  the  best  systems  of 
past  and  personal  experience, 

Striimi>el,  of  Leipsic,  has  lately  published  a  report 
of  a  case  of  general  anaesthesia,  where  there  was  entire 
Ijaralysis  of  taste  and  smeU,  and  blindness  of  the  left 
eye  and  deafness  of  the  right  ear,  and  also  entire  lack 
of  sensibihty  of  the  skin,  mucous  membranes,  and  of 
the  muscles.  One  eye  and  one  ear  alone  were  the 
means  of  communication  with  external  nature;  when 
this  one  sound  eye  was  closed  and  the  one  somid  ear 
was  stopped,  the  patient  in  a  few  minutes  fell  into 
deep  sleep. 

This  one  case  powerfully  illustrates  how  iiTitating  to 
the  brain  are  the  ordinary  waves  of  hght  and  sound. 
The  same  fact  is  proved  by  the  experience  of  eveiy 
one;  for  we  all  sleep  much  later  on  dark  mornings, 
and  when  we  take  a  nap  during  the  day  usually  wake 
up  after  an  hour  or  two.  In  the  hyperesthesia  of 
nervous  disease,  the  sensitiveness  of  the  optic  and 
auditory  nerves,  as  well  as  of  the  brain,  becomes  much 
exalted,  and  the  heed  of  avoiding  external  irritation 
all  the  more  imperative.  I  have  under  my  care  a 
man  who  has  Iwen  profoundly  exhausted  nervously 
and  sometimes  hysterical,  and  who,  when  he  feels  es- 
jx'cially  dei)ressed,  jmts  corks  in  both  eai-s  and  shuts 
liimself  uj)  in  a  dark  closet.  It  is  a  method  tliat  lias, 
liowever,  its  difficulties,  disadvantages,  and  failures, 
but  in  a  certain  class  of  nervous  diseases,  especially  in 
women,  the  benefits  far  overbalance  the  trouble  and 
sacrifice. 


184  NERVOUS  EXHAUSTION. 

Among  the  difficulties  are  the  prejudices,  and  fears, 
and  whims  of  friends,  and  the  apprehension  on  the 
part  of  the  patient  that  confinement  is  a  more  burden- 
some thing  than  it  is  really  found  to  be  by  those  who 
give  it  a  fair  trial;  but  when  these  preliminaries  are 
satisfactorily  arranged,  and  the  sufferer  has  once  put 
herself  under  treatment,  all  the  rest  is  comparatively 
easy;  in  much  shorter  time  than  one  would  suppose, 
she  becomes  accustomed  to  the  restraint;  the  appetite 
under  the  stimulus  of  electricity,  the  very  best  of 
tonics,  and  tempting  food,  is  often  much  better  than 
when  in  active  duties,  and  in  a  few  days  the  fat  begins 
to  roll  up  in  the  face,  and  subsequently  over  the  body. 
The  observations  of  Mitchell  and  Goodell  on  this  point 
are  verifiable. 

One  of  the  practical  difficulties,  for  the  solution  of 
which  no  mathematical  rule  can  be  given,  is  the  time 
required  for  this  rigid  confinement,  and  the  method  of 
bringing  back  the  patient  to  ordinary  life. 

Many  years  ago  I  observed  that  nervous  patients 
were  better  on  Sundays,  when  they  did  nothing,  than 
on  other  days;  and  that  even  the  nervously  dyspeptic 
could  eat  more  on  that  day,  and  with  less  distress  than 
on  secular  days.  For  a  time  the  reason  was  not  clear 
to  me.  It  is  the  repose  of  body  and  mind  that  makes 
it  possible  to  eat  so  much  on  this  day  of  rest,  and  thai 
makes  the  day  a  hygienic  blessing  to  civilization. 
There  are  patients  who  need  to  make  every  day  a  Sab- 
bath— to  have  sixty,  or  ninety,  or  more,  consecutive 
days  of  rest. 

The  isolation  from  friends  on  which  Charcot, 
Mitchell,  and  others  so  earnestly  insist,  I  do  not  always 
find  to  be  necessary;  it  is  certainly  unnecessary  with 
the  majority  of  such  patients;  some  of  the  best  possi- 
ble results  I  have  secured  when  the  patient  was  imder 


HYGIENE  OF  NERVOUS  EXHAUSTION.  185 

the  direct  care  of  relatives  and  friends.  Charcot  tells 
me  that  for  ten  years  he  has  been  accustomed  to  isolate 
patients,  not  even  allowing  their  mothers  to  see  them 
occasionally,  and  in  the  presence  of  an  attendant.  In 
the  use  of  this,  as  in  the  use  of  all  plans  and  devices 
for  overcoming  chronic  disease,  there  can  be  no  rou- 
tine, cast-iron  law;  each  case  is  a  different  case  from 
any  other,  with  different  symptoms,  history,  idiosyn- 
crasies, antagonisms  and  aflinities.  In  deciding  the 
question  whether  a  female  patient  is  or  is  not  to  be 
removed  from  home  and  friends,  the  character  of  the 
friends  themselves  is  to  be  considered:  if  they  are  un- 
duly emotional,  superstitious,  and  demonstrative;  if 
they  constantly  burden  and  weary  her  with  oppressive 
talk  and  attention,  then  removal  may  be  indispensable, 
without  which  all  treatment  is  thrown  away;  the  con- 
stant turning  of  the  patient's  mind  on  the  body  by 
conversation,  consultation,  and  sympathy  in  its  vari- 
ous modes  of  expression,  counter-balancing  manifold 
all  possible  therapeutic  agencies;  oil  and  water  are 
poured  on  the  same  fire,  a  gallon  of  the  one  to  a  gill  of 
the  other.  When  such  cases  are  taken  out  of  tliese 
really  hostile  influences,  and  carried  in  any  direction 
and  kei)t  resolutely  apart  from  those  who  know  and 
love  and  pity  them,  they  are  so  far  delivered  from  one 
of  the  worst  possible  exciting  causes  of  functional 
nervous  disease,  and  an  opportunity  is  given  for  the 
forces  of  nature  and  medication  to  work  together 
without  friction  toward  recovery.  In  all  forms  of  dis- 
ease, mental  therapeutics  is  often  more  useful  tlian 
any  otlier  kind  of  therai)eutics,  and  this  forced  seclu- 
sion is  a  powerful  and  legitimate  means  of  acting  on 
the  mind;  it  compels  tlie  patient  to  do  wliat  they  are 
far  too  nmch  disposed  to  do  of  themselves,  that  is,  re- 
main inac^^we,  and  this  systematic  inactivity  in  time 


186  NERVOUS    EXHAUSTION. 

tends  to  cure  the  desire  for  inactivity;  they  seek  for  a 
change,  and  long  for  exertion,  while  the  rest,  elec- 
tricity, and  tonics  give  them  strength  to  attempt  it. 

A  great  factor  in  these  cases  is  the  therapeutic 
power  of  a  radically  new  impression  of  any  kind; 
hence  the  real  advantage,  in  some  cases,  and  at  certain 
stages,  of  a  change  of  doctors,  even  from  a  superior  to 
an  inferior,  or  at  least,  a  radical  revolution  in  the 
mode  of  treatment. 

This  same  question  of  seclusion — restraint  or  non- 
restraint — comes  up  in  the  management  of  insanity, 
especially  in  the  early  stages  of  the  milder  forms  of 
melancholia.  In  these  cases  it  becomes  necessary  for 
the  physician  on  whom  the  responsibility  of  the  case 
rests  to  make  a  diagnosis  of  the  character  of  the 
patient's  friends  and.  surroundings,  before  deciding  the 
very  important  question  of  restraint  or  non-restraint. 
There  are  cases,  which  I  have  seen  in  my  own  practice, 
where  the  best  results,  satisfactory  both  in  rapidity  and 
permanence,  are  secured  by  treating  the  patients  at 
home  in  the  midst  of  her  friends,  who  care  for  her  and 
execute  the  directions  of  the  physician;  and  there  are 
cAses  where  speedy  removal  is  the  only  wise  course. 

Few  things  in  my  professional  experience  have  been 
more  pleasing  than  the  permanent  results  that  I  have 
been  enabled  to  obtain  in  severe  and  long-standing 
cases  of  hysteria,  hystero-epilepsy,  neurasthenia,  and 
allied  affections  in  nervous  women  when  treated  at 
home,  or  among  relatives  who  were  sufficiently  sensi- 
ble to  know  how  to  co-operate  with  the  required  treat- 
ment. I  recall  in  particular  an  aggravated  case  of 
hysteria  with  convulsions,  hallucinations,  and  pro- 
found depression,  that  was  taken  directly  to  the  resi- 
dence of  a  relative  physician,  and  kept  there  for  a 
number  of  weeks  under  treatment,  until,  as  a  reward 


HYGIENE  OF  NERVOUS  EXHAUSTION,  187 

of  perseverance,  she  ^\'as  permanently  restored,  and 
to  this  day  remains  well  and  active.  This  patient  was 
not  allowed  to  see  any  one  but  a  relative,  strangers 
being  systematically  excluded  whenever  they  called; 
and  yet  a  more  delightful  result  could  not  have  been 
expected  from  any  plan  of  treatment,  and  is,  I  am 
sure,  rarely  experienced  by  those  who  have  to  do  with 
cases  of  this  kind. 

The  main  reliance  in  this  case  was  general  faradiza- 
tion and  central  galvanization,  very  httle  local  or  med- 
ical treatment  being  used.  Some  years  ago  I  had 
under  care  a  young  lady  who  was  so  thoroughly  neu- 
rasthenic that  she  could  scarcely  move  about  the 
house,  the  result  mainly  of  over-work  and  confinement 
in  a  routine  occupation.  She  was  treated  in  the  house 
of  a  relative,  and  although  the  sym[)toms  were  unusu- 
ally obstinate,  and  a  most  extraordinary  sensitiveness 
to  medicine  of  nearly  all  kinds  made  it  impossible  to 
use  the  leading  sedatives  and  tonics,  yet  she  gradually 
improved,  and  last  year  I  saw  her  as  a  bride  with 
much  increase  of  flesh,  and  in  sufficient  health  to  walk 
two  or  three  miles. 

Brain-nork  in  Nervous  Diseases. — Nervous  invalids 
do  not  always  need  to  suspend  all  labor  of  the  brain — 
better,  indeed,  that  they  should  be  actively  though 
l)leasautly  employed.  The  most  distressing  cases  of 
neivous  debility  that  I  have  seen  have  been  in  men 
who  hav<.^  suddenly  retired  from  business.  When  a 
muscle  is  weakened  through  disease,  we  try  to 
strengthen  it  through  passive  and  moderate  active  ex- 
ercise, l)elieviiig  that  thereby  its  nutrition  is  improved. 
This  same  law  th(^  brain  must  obey.  The  feeble  and 
tired  brain,  like  the  feeble  and  tired  muscle,  needs  a 
certain  amount  of  gymnastics.  Labor  of  the  intellect 
of  the  higher  sort  saves  us  from  friction  of  tlie  emo- 


188  NERVOUS    EXHAUSTION. 

tions  of  the  lower  sort,  and  thus  becomes  a  positive 
and  valuable  remedial  ageiicy.  For  this  reason  I  rarely 
advise  patients  to  permanently  leave  their  business, 
provided  they  are  happy  and  prosperous  in  it;  but 
rather  to  fight  out  the  battle  on  the  lines  where  they 
are. 

6.  The  last  general  suggestion  is,  that  in  the  treat- 
ment of  nervous  disease,  we  should  study  with  all  our 
energy  the  psychology  of  our  patients;  we  must  make 
a  diagnosis  of  the  intellectual  character  as  well  as  of 
the  disease,  before  we  can  make  a  prognosis  or  adopt 
a  plan  of  treatment.  There  are  those  whose  minds  are 
so  organized,  lacking  some  quaHties  and  having  in 
excess  usually  a  preponderance  of  the  emotional,  with 
a  deficiency  of  the  higher  intellectual  qualities — that 
they  act  badly  under  any  treatment,  however  wise. 
Some  patients  take  a  pleasure  in  their  distresses;  it 
would  be  cruel  to  cure  them;  their  pains  are  their  pos- 
sessions. Any  man  wishing  to  make  them  well  would 
be  no  better  than  a  thief  or  a  robber.  There  are  those 
whose  chief  felicity  in  hfe  consists  in  doctoring  and 
being  doctored,  and  to  whom  the  removal  of  their 
bodily  ills  would  be  like  the  death  of  long-cherished 
friends.  When  such  persons  come  under  our  care, 
we  cannot  expect  any  treatment  to  be  as  successful  as 
with  those  of  strong  and  active  intellects,  who  under- 
state rather  than  magnify  their  troubles,  and  are  reso- 
lutely determined  to  get  well. 

On  the  other  hand,  there  are  some  who  are  organized 
to  bear  sickness;  they  do  not  need  to  be  well;  they  can 
be  laborious,  useful,  and  happy,  while  in  a  condition 
of  partial  invalidism;  provided  only  they  are  in  work- 
ing order,  they  are  content,  even  though  they  be  not 
entirely  free  from  weakness  and  pains. 

Other  conditions  being  the  same,  the  prognosis  is 


HYGIENE  OF  NERVOUS  EXHAUSTION.  180 

better,  the  greater  the  amount  of  intellect,  the  less  the 
quantity  of  emotion  in  a  patient.  Many  would  never 
have  been  sick  at  all  in  this  way,  but  for  the  very  pre- 
dominance of  their  emotional  nature.  This  is  as  true 
of  men  as  of  women,  and  is  true  of  some  of  the  most 
agreeable  and  excellent  people  in  society. 

I  have  observed  that  when  neurasthenia  attacks  one, 
he  is  apt  to  break  down  at  fu"st,  if  not  last,  at  the  point 
where  he  is  weakest  psychologically.  Morbid  fears, 
for  example,  are  most  hkely  to  attack  the  modest,  the 
quiet,  the  diffident  and  retiring;  although  I  have  seen 
them  occasionally  in  some  of  their  forms  in  the  airy, 
the  egotistical,  self -suffering,  and  conceited.  A  tho- 
roughly resolute  person  is  less  likely  to  be  hopeless 
and  despaiiing  in  nervous  exhaustion,  than  one  who 
is  shrinking  and  timid  and  distiiistful. 

Mental  Therapeutics. — In  reference  to  the  mental 
treatment  of  neurasthenia  and  allied  maladies,  there 
are  two  prevailing  errors.  First,  that  mind  alone 
without  any  objective  medication  or  influence,  is  all 
that  is  necessary;  and  secondly,  that  this  method  can 
be  employed  in  an  off  hand,  hai)hazard  manner,  with- 
out study  or  system.  To  rely  on  mental  therapeutics 
alone,  disregarding  all  electricity,  massage,  and  inter- 
nal medication,  is  unscientific,  and  in  many  cases  will 
be  unsuccessful;  the  mind  is  a  strong  foi'ce,  but  it  is 
not  the  only  force  that  can  be  used  for  the  control  of 
functional  nervous  affections.  Tliese  errors  seem  to 
have  arisen  from  the  popular  belief  that  the  symptoms 
of  neurasthenia,  as  hei-e  sot  forth,  are  imaginary,  hav- 
ing no  real  objective  existence,  and  that  they  are  to  be 
expelled  by  the  same  influonco— the  ])atient\s  own 
mind.  Granted  what  is  und('nial)le,  that  the  emo- 
tions, by  long  dwelling  upon  the  body,  may  excite 
various  diseases;  still,  disease  so  caused  is  as  real,  as 


190  NERVOUS    EXHAUSTION. 

serious  often,  as  disease  excited  in  any  other  way,  and 
may  need  as  active  treatment;  and  can  no  more  be 
blown  away  by  a  few  words  of  encouragement  or 
ridicule  than  can  an  attack  of  smaU-pox  or  tyj^hoid 
fever. 

All  these  functional,  like  all  organic,  diseases  can  be 
relieved  by  mental  treatment,  but  there  is  no  more 
reason  for  restricting  this  treatment  to  mental  thera- 
peutics in  these  than  in  any  other  morbid  states. 

Combination  of  Remedies — To  the  combination  of 
neurotics  I  have  given  much  thought  and  study, 
watching  the  effects  in  a  large  variety  of  diseases  in 
divers  stages  and  conditions.  A  combination  of  med- 
icines— provided  the  mixtures  be  made  with  judgment 
and  their  effects  are  carefully  watched — is  oftentimes 
of  greater  value  in  neurasthenia  and  alhed  affections 
than  any  one  remedy  when  used  alone;  the  prejudice 
against  what  is  called  polypharmacy,  like  the  prejudice 
against  cathai'tics,  is  derived  from  the  bad  use,  the 
abuse,  the  overuse  of  what,  when  Avisely  directed,  is 
a  sound  and  immensely  valuable  principle  of  therapeu- 
tics. After  we  have  found  out  the  physiological  and 
therapeutical  action  of  any  remedy,  we  can,  on  theo- 
retical principles,  logically  and  consistently  combine 
that  remedy  with  any  other  remedy  whose  physiologi- 
cal and  therapeutical  pi'operties  we  also  understand, 
with  the  justly  founded  expectation  that  the  two  will 
reinforce  and  aid  each  other  and  co-operate  in  bringing 
about  the  desired  effect.  In  practice  we  find  such  to 
be  the  case;  not  only  two,  but  three  and  more  drugs 
can  be  thus  combined  so  as  to  produce  a  therapeutical 
agent  far  superior  to  any  one  of  the  constituents  when 
used  alone. 

The  combination  of  external  with  internal  treatment, 
electricity,  massage,  counter-irritations,  and    various 


HYGIENE   OF   NERVOUS  EXHAUSTION.  191 

sedative  tonic  medications,  is  especially  efficacious  and 
desirable,  and  least  of  all  likely  to  produce  incompati- 
ble results.  The  popular  fashion  of  trying  one  remedy 
for  a  time,  then  another  and  another  in  succession, 
for  severe  cases  of  nervous  exhaustion,  is  as  unwise  as 
it  is  foolish  in  putting  a  single  horse  to  a  heavy  load, 
tire  him  out,  then  to  hitcli  on  another,  and  so  on,  in- 
stead of  harnessing  a  number  in  a  team,  and  have 
them  all  pull  together.  Where  the  very  best  remedy 
fails  when  used  alone,  it  may  succeed  when  reinforced 
by  a  number  of  other  remedies  or  modes  of  treatment, 
medical  or  hygienic. 

Enumeration  of  Principal  Remedies. — The  ancients 
classed  the  divinities  as  major  and  minor  —  Dii 
majoreSy  Dii  minores.  Similarly,  neurotics  may  be 
divided  into  major  and  minor  remedies. 

Among  the  major  remedies,  ergot  is  especially 
worthy  of  note.  Just  how  ergot  acts  in  nervous  dis- 
eases is  not  known,  nor  indeed  are  we  likely  to  know 
in  satisfactory  detail  the  action  of  any  remedy.  That 
ergot  contracts  the  blood-vessels,  and  thus  is  useful  in 
congestions  of  the  brain  and  spinal  cord,  is  one  of  the 
clearly  established  facts  in  physiology,  and  is  one  of 
the  few  definite,  solid  foundations  for  therapeutics; 
but  that  this  effect  on  the  blood-vessels  is  all  that  there 
is  in  ergot  in  its  action  on  the  body,  no  philosophical 
student  of  nervous  diseases  would  claim.  Indeed,  this 
contraction  of  the  blood-vessels  must  be  a  result  as 
well  as  a  cause.  Behind  and  beyond  all  this  there  is 
an  influence  whicli  we  cannot  analyze.  One  advan- 
tage of  ergot  is  the  immediateness  of  its  effects,  par- 
ticularly in  cerebral  and  spinal  hypera^niia.  Tlio  par- 
ticular doses  of  ergot  need  important  modifications  in 
special  cases.  In  some  instances,  very  large  quantities 
of  ergotine  may  be  given  with  benefit  and  without 


192  NERVOUS    EXHAUSTION 

any  harm  that  I  can  trace.  I  give  ergot  for  immediate 
effects,  for  sick  headaclies,  and  for  headaches  of  other 
kinds,  and,  for  long-continued  a.ction,  in  irritable  pros- 
tate, spermatorrhoea,  and  various  other  conditions. 
The  doses  indicated  in  the  books  are  no  guide. 

Arsenic. — Another  of  these  Dii  majores  of  neuro- 
therapeutics  is  arsenic  in  its  different  forms.  I  use, 
not  only  Fowler's  solution,  but  De  Valangin's,  with 
also  the  Enghsh  preparation  of  the  chloro-phosphide. 
Arsenic  is  a  remedy  the  effects  of  which  are  not,  as 
a  iTile,  felt  at  once.  It  needs  to  be  kept  up — to  be 
persevered  with  for  many  weeks,  oftentimes  for  many 
months.  In  some  cases,  no  good  comes  until  the 
physiological  effects  have  been  produced. 

Cannabis  Indica. — Another  remedy  that  perhaps 
will  become,  if  it  is  not  already,  one  of  the  major 
divinities  of  neurology,  is  cannabis  indica.  This 
remedy  has  the  reputation  of  untrustworthiness  and 
unreliability,  both  of  preparation  and  of  action.  This 
reputation  it  is  very  fortunately  losing.  I  find  that 
for  some  conditions  cannabis  indica  is  one  of  the  most 
trustworthy,  most  reliable,  and  valuable  of  remedies. 
It  is  one  of  the  drugs,  by  the  proper  use  of  which  the 
treatment  of  sick  headache,  for  example,  has  been 
within  a  few  years  revolutionized,  both  for  temporary 
relief  at  the  beginning  of  an  attack  and  during  the 
attack,  and  as  a  permanent  cure,  provided  its  action  is 
maintained  for  weeks  and  months.  It  is  one  of  the 
most  certain  and  convenient  and  agreeable  of  all  the 
preparations  used  in  neuro-therapeutics.  Its  quick 
and  permanent  influence  over  the  symptoms  of  head- 
ache suggests  its  great  value  in  other  conditions  alUed 
to  sick  headache,  or  from  which  sick  headache  springs; 
and  I  am  accustomed  now  to  use  it  in  the  different 
phases  or  manifestations  of  neurasthenia  and  kindred 


HYGIENE  OF  NERVOUS  EXHAUSTION.  193 

affections.  I  use  it  sometimes  alone,  sometimes  in 
combination  with  various  tonics  and  sedatives. 

Caffeine. — Another  remedy,  not  very  widely  known, 
but  one  the  value  of  which  is  easily  proved,  is  finely 
powdered  citrate  of  caffeine.  Some  years  since,  I 
called  the  attention  of  the  profession  to  the  value  of 
this  remedy  in  sick  headache  as  a  means  of  temporary 
rehef  at  the  beginning  of  an  attack;  very  many  phy- 
sicians have  obtained  the  same  results.  I  now  use  this 
remedy  for  other  symptoms  besides  sick  headache, 
such  as  backache— what  may  be  called  headache  in  the 
back — and  malaise,  general  depression.  A  disadvan- 
tage of  this  remedy  is,  that  it  produces  wakefulness, 
and  therefore  cannot  be  taken  in  the  latter  part  of  the 
day,  I  use  it  in  doses  of  from  0.18  to  0.30  grams  and 
repeat  if  needful. 

I  have  been  many  times  asked  why  the  drinking  of 
a  cup  of  coffee  will  not  have  the  same  effect  as  taking 
caffeine,  or  even  tea,  the  theine  of  which  much  resem- 
bles caffeine.  In  some  cases,  one  or  two  cui)s  of  coffee 
or  tea  will  have  the  same  temporary  effect  as  a  small 
dose  of  caffeine,  but  usually  there  is  not  sufficient  of 
tlie  active  principle  in  the  coffee  that  we  drhik  to 
relieve  severe  headache. 

Aubert  estimates  that  a  cup  of  coffee  contains  about 
0.1  to  0. 12  gms.  of  caffeine,  and  a  cup  of  strong  tea  a 
similar  quantity.  TJiis  amount  is  not  sufficient  to 
break  up  a  headache  attack,  for  wliich  T  prescribe 
quite  large  doses.  To  tliis  must  be  added,  that  the 
milk  and  sugar  are  likely  to  interfere  more  or  less,  es- 
pecially where  the  stomach  is  disturbed. 

Poisonous  Effects  of  Caffeine — Tea  Tasting  Caffeine- 
ism. — I  have  never  seen  any  serious  effects  from 
caffeine,  even  when  taken  very  freely,  but  in  one  case, 
the  wife  of  one  of  my  medical  friends,  who  seemed  to 
13 


194  NERVOUS  EXHAUSTION. 

have  an  idiosyncrasy  against  it,  just  as  one  may  have 
an  idiosyncrasy  against  any  other  drugs,  or  articles 
of  food. 

The  majority  of  persons  can  drink  quite  freely  of 
tea  aU  their  lives  without  being  perceptibly  harmed; 
this  is  the  experience  of  millions  upon  millions  of  the 
human  race  in  the  different  stages  of  semi-civilization 
and  high  civilization,  and  under  various  climes.  In 
our  high  civilization,  and  especially  in  America,  there 
is  developing  a  small,  though  increasing  number  of 
persons,  who  have  an  idiosyncrasy  against  tea,  are 
made  nervous  and  kept  awake  by  a  very  slight  dose, 
and  cannot  habitually  use  it. 

Quite  a  number  of  years  ago,  I  had  under  care  a  case 
of  cerebral  disease  in  a  gentleman  who  had  been  a 
"tea  taster"  downtown,  and  his  wife  attributed  his 
malady  to  his  excess  in  the  drinking  and  inhalation  of 
tea.  The  subject  was  then  an  entirely  new  one  to  me, 
and  I  took  pains  to  investigate  the  health  of  the  tea 
tasters  in  this  city.  The  general  result  of  these  inves- 
tigations, which  were  never  published  or  even  written 
out,  were  as  follows: 

1.  That  the  great  majority  of  tea  tasters  were  not 
perceptibly  injured  by  their  occupation.  There  were 
instances  of  persons  who  had  pursued  this  calling  for 
very  many  years  unto  old  age  and  had  not  been 
harmed  thereby.  In  the  case  of  my  own  patient, 
there  was  no  proof  that  the  tea  tasting  was  even  an 
incidental  factor  in  the  causation  of  his  brain  dis- 
order. 

2.  A  small  percentage  were  apparently  made  nerv- 
ous by  professional  tea  tasting,  just  as  some  are  made 
nervous  by  excessive  tea  drinking.  Their  symptoms 
are  wakefulness,  nervousness,  irritable  heart,  with 
palpitation  and  nervous  dyspepsia,  and  so  forth. 


HYGIENE   OF   NERVOUS  EXHAUSTION.  195 

When  Dr.  W.  J.  Morton  read  his  paper '  before  the 
American  Neurological  Association,  I  concluded  that 
he  must  have  investigated  the  matter  more  thoroughly 
than  I,  or  that,  thi'ough  the  increasing  nerve-sensitive- 
ness of  the  age,  the  number  of  persons  specially  sus- 
ceptible to  the  active  principle  of  tea  had  increased.  I 
\vas,  therefore,  much  interested  in  a  paper  just  pub- 
lished on  Tea  Tasters  and  the  Heal thfahi  ess  of  their 
Pursuit,  by  Dr.  C  L.  Dana,^  wherein  he  concludes 
from  an  investigation  since  the  publication  of  Dr.  Mor- 
ton's paper,  that  tea  tasting  as  a  profession  is  not 
injurious  to  health. 

Somewhere  between  these  extremes,  but  nearer  to 
Dr.  Dana  than  to  Dr.  Morton,  the  tmth  probably  lies. 
It  is  certain  that  Dr.  Dana  obtained  the  same  results 
from  his  investigations  that  I  obtained,  ten  years  be- 
fore, and  it  is  clear,  also,  that  his  inquiry  was  more 
thorough  than  mine. 

It  is  certain,  on  the  other  hand,  that  some  individ- 
uals cannot  tolerate  tea,  and  so  far  forth  Dr.  Morton 
is  right.  This  idiosyncrasy  I  meet  with  among  my 
nervous  patients.  To  this  array  of  symptoms  pro- 
duced by  tea  or  coffee  I  would  suggest  the  term 
caffeinism^  which  is  analogous  to  chloralisin,  bromism, 
and  alcohohsm.  These  symptoms  are  just  such  symp* 
fonis  as  arc  f GUI  id  iu  veurasfhenia  from  other  exciting 
can.sr.s;  iltey  are  not  of  theniselres  (lia<jnostic.  Only 
the  histoiy  and  very  close  study  of  any  case  makes  it 
possible  to  establish  beyond  doubt  that  such  and  such 
neurasthenic  symptoms  as  morbid  fear,  nervous  dys- 
jK^psia,  vertigo,  sick  headache,  insomnia,  are  the  sole 
effects  of  excess  in  the  use  or  tasting  of  tea.     It  Is  not 

'  Tea  l)rii)kt»rs'  Disonlcr,  or  the  Toxic  EfTects  of  Tea.     "Jour- 
nal of  Nervous  I)is(';is(»K,"  Octolicr,  IHTl). 
'  "  Medical  Record,"  Jan.  24th,  1»«0. 


196  NERVOUS  EXHAUSTION. 

impossible  that  Dr.  Morton  may  have  been  misled  in 
this  way.  Very  recently,  since  the  publication  of  Dr. 
Dana's  paper,  I  requested  a  former  j^atient  to  repeat 
the  inquiries  down -town,  among  the  class  of  tea  brokers 
with  whom  he  was  somewhat  acquainted.  The  result 
of  his  investigation  was  identical  with  that  obtained 
by  Dr.  Dana  and  myself.  He  found  a  number  of  aged 
and  healthy  individuals  among  the  tea  tasters. 

In  our  climate,  coffee  is  far  more  likely  to  produce 
caffeinism  than  tea.  In  the  South,  and  in  warm 
climates  generally,  coffee  is  tolerated  much  better  than 
in  cold  climates;  with  tea  tliis  difference  is  less 
marked.  I  have  often  produced  mild  temporary 
symptoms  of  caffeinism  by  the  administration  of  re- 
peated doses  of  caffeine  for  sick  headache,  but  caffein- 
ism thus  induced  passes  away  in  a  day  or  two.  The 
best  antidote  to  caffeinism  is  found  in  the  bromides. 

Coca. — AUied  to  caffeine  is  coca,  belonging,  indeed, 
to  the  same  family;  indeed,  it  is  the  active  principle 
common  to  coffee,  tea,  guarana,  and  chocolate.  The 
value  of  coca  as  a  means  of  presei^ving  the  strength, 
while  abstaining  from  ordinary  food,  is  erroneously 
exaggerated  in  the  stock  anecdotes  that  appear  in  our 
medical  hterature  on  this  subject;  but  it  has,  without 
doubt,  a  special  and  most  interesting  sustaining  and 
tonic  power.  It  relieves  the  pain  and  uneasiness  that 
foUow  over-exertion,  and  the  peculiar  distress  that 
comes  from  sleepless  nights,  for  which  purpose,  I  may 
say,  caffeine  may  also  be  used. 

Zinc  Combinations. — The  zinc  preparations,  partic- 
ularly the  bromide,  valerianate,  and  oxide,  are  seda- 
tives of  very  great  value  in  various  neurasthenias  and 
I  use  them  with  gi-eat  freedom. 

The  zincs  I  use  much  in  choreic  disorders;  one  of 
my  often  used  prescriptions,  which,  however,  I  fre- 


HYGIENE  OF  NERVOUS  EXHAUSTION.  197 

quently  modify  to  suit  special  cases,  is  the  follow- 
ing: 

Bromide  zinc, 
Valerianate  zinc. 

Oxide  zinc aa  .065 

Phosphide  zinc 003 

For  one  pill. 

Sometimes  macrotin  is  added  to  the  above.  It  is  a 
remedy,  the  value  of  which  in  choreic  conditions  is 
undeniable,  and  I  am  persuaded  that  its  use  need  not 
be  restricted  to  those  conditions. 

Duhoisia,  the  new  remedy  from  Australia,  is  Ukely 
to  take  a  minor  if  not  a  major  place  among  the  re- 
sources of  the  neurologist.  Its  effect  is  somewhat  Uke 
that  of  atropme,  but  yet  not  entirely  like  it;  and,  for 
the  symptom  of  hyperidrosis,  seems  to  be  more  effec- 
tive, according  to  experiments  that  I  have  made 
with  it. 

There  are  three  other  remedies  which  I  use  consider- 
ably, particularly  in  renal  and  bladder  compUcations, 
and  genito-urinary  distui'bances,  viz.,  the  trailing 
arbutus,  eucalyptus,  and  hydrastis.  I  believe  that 
these  remedies,  which  I  often  give  in  combination, 
have  a  tonic  power,  not  only  in  sexual  or  genito- 
urinary neurasthenia,  but  are  of  service  even  where 
there  is  no  genito-urinary  complication. 

I  have  used  with  satisfaction  the  following  combina- 
tion: 

Fluid  extr.  epigea  repens, 
Fluid  extr.  eucalyi)tus, 
Fluid  extr,  hydrastis. 

Fluid  extr.  jaboraudi aa  32  grams. 

Five  grams  a  dose. 

Bromides.— It  is  impossible  to  speak  of  the  treat- 


198  NERVOUS  EXHAUSTION. 

ment  of  this  class  of  troubles  without  referring  to  the 
bromides  of  potassium,  ammonium,  and  sodium  and 
hme,  and  lithium.  The  bromide  of  manganese^  if  it 
could  be  made  at  a  reasonable  cost,  might  be  an  addi- 
tion to  our  Kst  of  the  bromides.  Of  the  bromides  now 
in  use,  the  sodium  bromides  may  now  be  classed 
among  the  old  remedies.  Their  great  value  in  epilepsy 
has  long  been  known.  They  are  not,  however,  so  well 
understood  in  other  nervous  diseases  of  a  functional 
character.  The  bromides  may  be  used  in  large  doses, 
frequently  repeated,  until  the  powerful  sedative  effect 
is  produced,  even  when  there  is  no  sleeplessness;  those 
who  use  the  bromides  in  this  way  must  know  where 
to  stoj)  or  to  reduce  the  dose.  They  are  not  to  be  used 
in  this  way  domestically. 

The  bromides,  like  electricity  and  massage,  give  the 
system  rest  by  slowing  dowQ  and  steadying  the  nerve- 
activity. 

In  order  to  get  complete  effects  of  the  bromides, 
large  doses  are  often  necessary.  The  doses  indicated 
,  in  the  books  are  of  little  value  in  many  cases.  When  A 
'  freely  diluted  with  water,  bromides  can  be  given  in 
two- gram  and  four  gram  doses,  with  effects  that  are 
clearly  perceptible  within  a  day  or  two,  or  within  a 
few  days,  while  the  same  bromides  given  in  the  doses 
indicated  in  the  books,  for  a  long  time,  would  have  no 
influence.  Given  in  this  way,  they  do  not  injure  the 
stomach,  or  the  neiwous  system,  except  in  rare  cases, 
where  there  is  an  idiosyncrasy  against  them.  The 
bromides  are  not  to  be  taken  in  these  large  doses  for  a 
long  time — the  physician  is  to  study  their  effects,  and 
stop  them,  sometimes,  in  a  few  days  after  they  are 
begun,  substituting  a  different  mode  of  treatment  of 
some  kind;  and  there  are  individuals  to  whom  they 
are  not  to  be  given  in  any  dose.     I  not  unfrequently 


HYGIENE  OF  NERVOUS  EXHAUSTION,  199 

see  cases  that  have  been  harmed  by  injudiciously  using 
the  bromides. 

They  are  used  too  long;  they  are  too  popular  as 
domestic  remedies.  The  great  question  is,  to  know 
when  to  stop  using  them.  This  question  is  to  be  an 
swered  differently  to  all  different  circumstances. 
There  are  some  temperaments  that  are  injured  by  the 
average  dose  of  them,  and  there  are  other  tempera- 
ments that  can  bear  them  in  very  large  doses.  They 
do  pot  ^-"''^  nfturastjioni.'^^  and  when  used  too  long — 
like  chloral — they  cause  it;  but  rightly  used — stopped 
when  they  have  been  sufficiently  used — they  are  a 
means  of  highest  value. 

By  a  proper  combination  with  Fowler's  solution,  the 
bromic  acne  can  usually  be  prevented. 

It  is  sometimes  of  the  highest  advantage  to  mildly 
bromize  a  patient  for  a  few  days  or  longer — bromism 
giv^es  the  system  a  rest,  hke  a  vacation. 

Symptoms  of  bromism,  even  wlien  (juito  profound, 
generally  pass  away  in  a  few  days  after  stopping  the 
remedy,  and  if  necessary,  the  disappearance  of  these 
symptoms  can  be  hastened  by  tonics. 

Chloral. — A  remedy  to  be  ranked  with  alcohol  and 
opium  is  chloral,  which  is  now  greatly  used,  and 
greatly  over  used. 

I  mention  it  here,  not  as  a  remedy  to  be  prescribed 
usually  for  neurasthenia,  but  for  tlie  same  reason  that 
I  mention  opium  and  alcohol;  that  is,  as  one  of  the 
remedies  to  be  avoided.  Indeed,  one  of  the  fii'st  signs 
and  proofs  of  good  results  of  the  treatment  of  these 
cases  is,  that  tliey  can  dispense  with  their  opium  and 
alcohol,  or  chloral;  and  this  is  one  of  the  imi)ortant 
objects  for  which  many  of  these  cases  consult  me. 

Forcing  sleep  by  large  doses  of  chloral  night  after 
night  is  not,  in   any  sense,  a  treatment  of  neuras- 


200  NERVOUS  EXHAUSTION. 

thenia,  bat  rather  one  of  the  means  of  bringing  on 
certain  phases  of  that  state.  Chloral,  if  used  at  all, 
should  be  used  only  under  the  advice  of  a  physician, 
just  as  with  opium  and  alcohol.  If  ever  I  use  chloral, 
it  is  usually  but  for  a  time,  to  bridge  over  a  certain 
crisis,  and  usually  in  combination  with  other  remedies 
which,  to  a  certain  extent,  mitigate  its  evil  effects. 

Chloral  Asthenopia. — One  of  the  evil  effects  of  chlo- 
ral, concerning  which  little  seems  to  be  known,  is  an 
irritable  condition  of  the  eyes.  A  lady  that  I  know, 
and  who  has  been  accustomed  to  use  considerable 
chloral,  at  times  is  very  likely  to  have  an  attack  of 
weak  eyes,  with  choreic  movements  of  the  lids,  and 
profuse  watering,  with  sensitiveness  to  light,  and  a 
smarting  and  stinging  sensation.  A  number  of  cases 
of  a  like  character  have  been  brought  to  my  atten- 
tion, I  observed  in  the  journals,  recently,  two  or 
three  reports  of  somewhat  similar  cases. 

The  use  of  chloral,  indeed,  is  a  growing  evil,  both  in 
this  country  and  in  England.  Many  of  our  opium- 
eaters  are  also  chloral  takers;  the  helpless  sufferer 
being  the  slave  of  t  vvo  tyrants  at  once.  It  is  one  of 
the  problems  of  this  age,  how  to  stop  this  rapidly  in- 
creasing habit  of  taking  drugs  that  force  sleep.  It  is 
designed  that  this  treatise,  and  especially  this  chapter, 
shall  be  a  help  tow^ard  the  solution  of  the  problem. 

Strychnia  is  one  of  our  older  remedies,  and  I  use  it 
sometimes  alone,  but  very  frequently  in  combination 
with  other  remedies;  yet  it  cannot  be  used  in  all  cases, 
for  sometimes  it  has  a  depressing  effect.  In  other 
cases,  it  is  too  exciting. 

Opium,  in  small  doses,  is  excellent  for  many  phases 
of  neurasthenia;  and  were  it  not  for  the  danger  of 
forming  the  opium  habit,  I  should  use  it  more  fre- 
quently than  I  do.     I  am  obhged  to  treat  too  many 


HYGIENE  OF  NERVOUS  EXHAUSTION.  201 

cases  of  the  opium  habit  to  be  reckless  in  using  opium 
as  a  remedy.  Very  closely  watched,  it  is  excellent  in 
certain  forms  of  hypochondria  and  melancholia. 

Alcohol  also,  in  the  fomi  of  wine,  particularly  claret 
and  Burgundy,  is  to  be  advised  in  some  cases  of  this 
kind,  bat  not  recklessly,  or  without  reference  to  the 
age,  character,  and  temperament  of  the  patient. 
Alcohol  is,  for  some,  one  of  the  best  of  our  hypnotics, 
in  cases  where  the  bromides  fail  to  produce  sleep. 
\^niere  chloral  causes  severe  headache  next  morning, 
claret  wine,  freely  used,  may  produce  satisfactory 
effects,  without  any  unpleasant  after-effects.  I  do  not 
mention  this  as  a  general  prescription;  I  simply  say 
there  are  cases  of  which  the  physician  must  judge.  It 
has  the  same  objection,  however,  as  opium — that  its 
use  may  lead  to  inebriety.  In  the  treatment  of  nerv- 
ous cases,  it  is  sometimes  necessary  to  use  all  of  these 
potent  remedies  in  incredibly  and  absurdly  small 
d^ifi^. 

The  mineral  acids  are  likewise  old  remedies,  but 
they  are  good  remedies.  Dilute  nitro-muriatic  acid, 
either  alone  or  combined  with  the  vegetable  bitters,  I 
use  in  different  forms  of  nervous  exhaustion,  especially 
where  the  urine  is  over-loaded,  as  it  often  is,  with 
oxalates  and  urates.  The  gi'eat  results  claimed  for 
them  by  Golding  Bird  are  not,  however,  in  all  respects 
verifiable.  As  a  routine,  unbending  treatment  for  the 
symptom  oxaluria,  it  is  as  unscientific  as  possible. 

Aromatic  sulphuric  acid,  in  the  ordinary  dose,  seems 
to  act  in  some  cases  with  almost  specific  power. 

Of  cod-liver  oil  I  may  say  that  it  probably  does 
i  more  for  the  nervous  than  it  does  for  the  consumptive. 
*  Oil  and  fats — like  cream  and  butter — are  nerve  food, 
J  and  if  used  judiciously,  as  the  stomach  can  bear  them, 
^  act  both  as  food  and  as  medicine.     The  oil  I  use  gen- 


202  NERVOUS  EXHAUSTION. 

erally  in  the  form  of  emulsion,  and  I  use  it  with  great 
freedom. 

The  Phosphates. — Of  phosphates  this  can  be  said: 
that,  hke  iron  and  quinine,  they  belong  to  the  Kst  of 
over-praised  and  over-used  remedies,  at  least  in  their 
relations  to  neurasthenia.  There  is  a  fashion  for 
phosphates  just  now,  and  when  men  become  neuras- 
thenic, they  think  they  are  on  the  road  to  health  if 
they  take  some  of  the  phosphates  or  phosphites.  Now, 
these  phosphates  and  phosphoruses  and  phosphites 
are  good  remedies  in  nervous  troubles;  but  if  they  had 
anything  like  the  specific  power  claimed  for  them, 
there  would  be  little  need  for  treating  these  cases; 
most  of  the  patients  that  I  see,  have  taken  them  in 
abundance.'  All  these  stock  remedies  have  a  certain 
power  which,  in  very  many  cases,  they  soon  expend 
— they  reach  the  limit  of  effect,  beyond  which  they 
cannot  be  forced. 

Koumiss. — Another  new  remedy,  or  comparatively 
new  to  this  country,  is  koumiss — fermented  milk. 
The  power  of  this  remedy  to  produce  sleep  is  very 
great,  and  very  satisfactory.  It  is  a  means  of  nourish- 
ing the  body,  without  disturbing  or  even  using  the 
stomach  to  any  very  great  degree.  Koumiss  is  really 
digested  milk,  and  is  absorbed  and  taken  up  into  the 
system  without  any  strain  upon  the  digestive  appar- 
atus. My  friend,  Dr.  Brush,  who  has  given  attention 
to  the  study  of  this  subject,  tells  me  that  from  experi- 
ments which  he  made  some  time  since,  it  was  pretty 
clearly  proved  that  the  alcohol  which  the  koumiss 
contains  was  used  up  in  the  system  and  not  elimin- 
ated.    I  am  persuaded  that  the  use  of  koumiss  in  the 

'  Dr.  Robert  T.  Edes,  of  Boston,  has  lately  published,  in  the 
"Boston  Medical  and  Surgical  Journal"  (January  15th,  1880),  a 
very  common-sense  essay  on  this  subject. 


HYGIENE   OP   NERVOUS   EXHAUSTION.  203 

future  is  to  be  very  widely  extended,  for  all  conditions 
where  nutrition  is  difficult— not  only  in  adults,  but  in 
children.  The  one  disadvantage  of  koumiss,  in  some 
cases — that  it  constipates  the  bowels — is  to  be  met  by 
laxatives. 

External  Modes  of  Treatment. — A  feature  in  the 
therapeutics  of  all  chronic  nervous  disoidors  is  the  roll 
assigned  to  external  appUcations  of  various  kinds. 
Among  the  more  prominent  of  these  are  electricity, 
water,  massage,  and  counter-irritation — all  of  which, 
by  virtue  of  their  alterative  or  changing  action,  may 
be  to  produce  sedative  and  tonic  effects. 

These  are  aU  old  remedies:  they  have  been  crowned 
by  the  approving  experience  of  many  generations;  but 
only  recently  can  they  be  said  to  have  been  formally 
introduced  into  science,  and  made  a  part  of  the  sys- 
tematic therai:)eutics  of  scholarly  physicians. 

The  chief  of  these  four  modes  of  treatment  is  un- 
doubtedly electricity,  which,  with  a  rapidity  that  has 
perhaps  no  parallel,  considering  the  difficulties  in  the 
way  of  its  use  and  the  prejudices  against  it,  has  forced 
its  way  into  science. 

Electricity  is  now  regarded  as  a  mode  of  motion — 
analogous  to  and  correlated  to  the  other  great  forces, 
as  light,  heat,  and  capable  of  being  transformed  into 
tliem.  When  an  electric  curi'ent  passes  through  tlie 
body,  it  causes  a  molecular  disturbance — a  change,  an 
alteration,  l)y  which  the  nutrition  is  modified,  and  con- 
sequently pain  relieved  and  strength  imparted.  It  is 
not  the  electricity  remaining  in  the  body  that  accom- 
l)Iislies  this,  bub  the  results  of  the  passage  of  electricity 
througli  the  body;  the  effect  of  the  molecular  motion 
on  nutrition,  the  modification  of  the  vital  processes, 
through  the  disturbances  excited  by  the  vil)ratioiis  tliat 
give  rise  to  what  we  call  electricity.     The  antique  fluid 


204  NERVOUS   EXHAUSTION. 

theories  of  electricity  are  powerless  to  explain,  even 
in  a  general  way,  the  rationale  of  its  action  in  disease. 
Applied  to  the  body,  electricity  acts  both  directly  and 
reflexly — directly  on  the  part  to  which  the  application 
is  made;  indirectly  through  the  reflex  function  of  the 
nerves. 

The  galvanic  belts,  so  much  advertised,  are  of  no 
value  in  nervous  exhaustion. 

In  the  treatment  of  neurasthenia,  the  best  methods 
of  using  electricity  are  general  faradization  and  central 
galvanization,  but  if  there  be  special  or  local  disorder, 
as  prostatic  or  ovarian  irritation,  then  local  faradiza- 
tion and  galvanization  are  also  required. 

In  the  treatment  of  a  new  case,  and  until  we  have 
learned  the  temperament  of  the  patient,  and  the  way 
he  responds  to  electricity,  it  is  proper  always  to  employ 
mild  currents,  and  for  the  same  reason  that  it  is 
always  best  to  begin  with  a  minimum  dose  of  any 
remedy.  But,  when  necessary,  it  is  also  well  to  test 
the  full  physiological  effects  of  the  remedy  before  giv- 
ing up  a  case.  I  am  convinced  that  in  many  cases 
electricity  wiU  not  give  extraordinary  effects  until  we 
have  produced  the  physiological  effects  upon  the 
patient.  To  begin  treatment  with  the  excitation  of 
these  symptoms  is  unwise  as  a  rule;  very  many  per- 
sons are  over-galvanized  and  over-faradized.  Every 
case  in  this  respect  must  be  itself  a  study.  I  formerly 
believed  that  an  application  once  a  day  was,  to  say  the 
least,  enough ;  but  I  now  know  from  experience  that 
applications  twice  a  day,  and,  in  some  cases,  applica- 
tions quite  prolonged,  are  advantageous. 

Many  years  ago,  I  pointed  out  the  fact  that  there  are 
certain  temperaments  that  do  not  bear  electricity,  or 
bear  it  very  badly,  and  must  be  treated  with  mild  cur- 
rents, and  with  quite  long  intervals  between  the  ap- 


HYGIENE   OF   NERVOUS   EXHAUSTION.  205 

plications.  Any  new  cases  that  come  under  our  care 
may,  for  all  we  know,  have  this  temperament.  These 
propositions  apply  to  all  the  other  remedies  of  which  I 
am  to  speak.' 

In  regard  to  this  general  question  of  dosage  of  elec- 
tricity and  adaptation  to  temperament, disease,  and  idio- 
syncrasy, I  may  observe  that  the  dosage  of  this  agent, 
as  of  some  of  our  most  used  drugs,  has  been  modified 
of  late  in  a  very  interesting  way.  It  has  been  proved 
by  trial  that  the  difference  in  effect  between  a  large 
and  even  an  average  dose  and  a  very  small  dose  is 
great  and  radical;  and  that  in  different  doses  the  same 
remedy  may  be  used  in  very  different  diseases;  thus 
the  domain  of  therapeutics  has  been  greatly  widened. 
Tincture  of  cantharides,  which  in  doses  of  ten  or 
twenty  drops  causes  irritation  of  the  urethra  and  per- 
haps strangury,  in  doses  of  one  drop  or  less  is  one  of 
the  best  of  all  sedatives  for  irritation  of  the  prostatic 
urethra  and  the  neck  of  the  bladder;  aloes,  which  is  a 
long  known  irritant  for  the  lower  bowel,  has  been  suc- 
cessfully used  in  drop  doses  for  prolapsus  ani;  arsenic, 
which  is  so  liable,  even  in  moderate  doses,  to  produce 
inflammation  of  the  stomach,  in  doses  of  one  or  two 
drops,  or  perhaps  half  a  drop  of  Fowler's  solution, 
sometimes  acts  with  specific  and  most  remarkable 
power  on  the  irritated  and  inflamed  mucous  mem- 
brane of  the  stomach.  Podophyllin,  which  in  ordinary 
doses  is  so  strongly  cathartic,  Dr.  Mays  has  found,  in 
lialf-drop  doses  of  tlie  fluid  extract,  to  be  very  excel- 
lent in  infantile  diaiThoea.     Calomel,  when  given  in 

'  For  more  details  of  tliis  branch  of  therapeiitics  the  reader  is 
referred  to  "A  Practical  Treatise  on  the  Medical  and  Surffical 
Uses  of  Klectricity,"  by  Geo.  M.  Heard,  A.M.,  M.D.,  and  A.  D. 
Rockwell,  A.M.,  M.D.  Sixth  Edition,  revised  by  A.  D.  Rockwell, 
A.M.,  M.D.     Wm.  Wood  &  Co.,  rublishers,  N.  Y. 


206  NERVOUS  EXHAUSTION. 

immense  doses  of  from  20  grains  to  half  a  drachm  and 
even  a  teaspoonful  (as  Dr.  Lente  tells  me  is  customary 
in  some  parts  of  the  South),  is  said  to  have  a  local 
sedative  effect,  with  no  more  cathartic  effect  than  it 
will  produce  by  a  veiy  small  dose. 

The  difference  between  a  dose  of  ten  or  twenty 
grains,  and  of  oire  en*  two  drachms  of  bromide  of  potas 
sium,  or  of  any  of  the  broixddes,  not  only  in  epilepsy, 
but  also  in  a  veiy  large  variety  of  functional  nervous 
diseases,  is  all  the  difference  between  getting  no  effect 
at  all,  and  getting  some  of  the  most  remarkable  thera- 
peutic effects  in  the  history  of  medicine. 

Similarly,  iodide  of  potassium  in  sypliihs  must  be 
given  by  ounces;  hkewise  with  muriate  of  ammonia, 
in  certain  chest  affections.  In  the  southern  portions 
of  the  United  States,  quinine  must  be  given  by  the 
half-drachm,  or  even  by  the  drachm,  to  break  up 
chills  and  fever.  Ergot,  in  the  old-fashioned  dose  of 
ten  or  twelve  drops  of  fluid  extract,  does  little  good  in 
nervous  affections;  but  given  by  the  teaspoonful  and 
two  teaspoonfuls  of  fluid  extract,  or  in  five  or  ten 
grains  of  the  ergotine,  is  one  of  the  greatest  and  most 
successful  of  all  the  remedies  of  neuro- therapeutics. 
Sulphide  of  calcium,  until  very  lately  given  in  doses  of 
a  tenth  of  a  grain,  for  various  uses,  we  are  now  wont 
to  give  in  doses  of  from  one -half  to  two  grains,  for 
diabetes  and  other  affections,  Avithout  injurious  effect, 
but  with  beneficial  effects  that  small  doses  did  not 
even  suggest. 

Strychnine,  not  only  in  paralysis,  but  in  other  nerv- 
ous troubles,  is,  in  many  cases,  never  felt  at  all,  until 
it  is  pushed  to  a  dose  far  transcending  the  dose  ordered 
in  the  books,  or  mitil  there  is  severe  twitching  of  the 
muscles,  with  head-symptoms. 

What  is  true  of  these  famihar  drugs  is  even  more 


HYGIENE   OF  NERVOUS  EXHAUSTION.  207 

directly  and  demonstrably  ti-ue  of  electricity.  The 
scientific  study  of  the  dosage  of  electricity  widens  the 
range  of  its  use  in  therapeutics,  and  at  the  same  time 
makes  our  electro- therapeutics  more  precise  and  satis- 
factory. 

[In  the  treatment  of  the  central  nei'\''ous  system  by 
the  galvanic  current  it  is  essential  that  the  dosage 
be  accurately  measured  and  carefully  registered. 

For  this  purpose  the  milliamperemeter  is  a  necessity. 
This  instrument  of  precision  has  been  used  in  electro- 
therapeutics only  a  comparatively  short  time,  but  it  is 
of  immense  value.  It  relieves  the  mind  of  all  anxiety 
in  regard  to  many  minor  details,  and  he  who  has  once 
tested  it  wall  never  willingly  be  without  it.  To  the 
tyro  it  is  a  necessity. 

Without  it  he  will  find  himself  working  entirely  in 
the  dark,  and  a  beginner  should  no  more  think  of  at- 
tempting serious  work  without  his  indicator  of  current  • 
strength,  than  he  should  administer  his  drugs  without 
his  apothecary's  measure.  Another  appliance  conven- 
ient to  have,  but  in  no  sense  essential,  is  the  rheostat, 
the  utility  of  which  I  will  briefly  illustrate.  To-day, 
for  exami)lc,  the  observer  notices  that  the  current 
from  a  given  number  of  cells  is  painfully  felt  by  the 
patient,  while  to-morrow  the  same  strength  applied  to 
the  same  patient  may  be  felt  Init  slightly.  If  no  mil- 
liamperemeter is  used,  the  mystery  seems  very  great, 
and  I  know  not  how  many  times  I  have  been  asked 
for  an  explanation. 

If,  however,  tlie  cun-ent  is  measured  the  mystery  is 
solved,  for  it  is  observed  that  when  pain  follows  the 
application  a  gi-eater  number  of  milliampercs  is  regis- 
tered than  wh(Mi  no  pain  is  produced. 

All  this  is  explained  by  the  fact  that  the  skin  varies 


208  NERVOUS  EXHAUSTION. 

very  much  on  different  days  and  in  different  physical 
conditions  as  to  its  conductibility. 

Now  if  on  one  day,  in  an  ai)phcation  to  a  patient  of 
a  current  from  thirty  cells,  the  meter  registers  thirty 
milliamperes,  and  on  the  next  the  same  number  of 
cells,  with  the  electrodes  applied  on  the  same  portion 
of  the  body,  causes  the  meter  to  indicate  but  twenty, 
we  know  that  the  patient  is  offering  a  far  greater  re- 
sistance to  the  current  on  the  second  day  than  on  the 
first.  It  is  not  essential,  for  practical  purposes,  that 
we  know  just  what  that  resistance  is,  but  it  is  desira- 
ble and  interesting  to  know,  and  the  rheostat  supplies 
this  knowledge  with  absolute  exactness.  In  order  to 
find  out  the  resistance  when  the  registration  is  thirty, 
we  substitute  a  rheostat  for  the  body  of  the  patient 
and  introduce  a  number  of  ohms  in  the  circuit  suffi- 
cient to  hold  the  needle  at  thirty.  If  the  number  of 
ohms  found  necessary  is  three  thousand,  then  three 
thousand  is  exactly  the  resistance  offered  by  the  body 
of  the  patient  on  the  first  day.  To  find  out  the  resist- 
ance when  the  meter  registers  but  twenty,  the  same 
process  is  repeated,  and  if  the  number  of  ohms  regis- 
tered is  five  thousand,  we  know  that  five  thousand 
ohms  is  the  amount  of  resistance^ffered. 

The  utility  of  the  rheostat  in  therapeutics  is  more 
especially  in  the  direction  of  enabling  us  to  increase 
or  decrease  the  current  gradually,  and  without  shock, 
and  in  neurasthenic  cases  this  is  of  especial  conse- 
quence. After  intercalating  a  resistance  of  one  thou- 
sand or  more  ohms  we  bring  into  action  the  number 
of  cells  that  will  probably  be  required.  By  gradually 
reducing  the  resistance  in  the  rheostat,  the  milliam- 
peremeter  soon  marks  the  degree  of  quantity  required. 
To  decrease  the  current,  the  resistance  in  the  rheostat 
is  as  gradually  increased  until  the  needle  points  to  0, 


HYGIENE  OF  NERVOUS  EXHAUSTION.  209 

an  indication  that  the  resistance  equals  the  strength  of 
the  current.  The  Germans  taught  the  use  of  ridicu- 
lously weak  currents,  and,  influenced  by  these  teach- 
ings and  by  a  natural  respect  for  an  agent  so  subtle, 
the  average  degree  of  strength  employed  when  first 
I  began  the  use  of  galvanism,  and  for  years  subse- 
quently, indeed,  was  in  many  cases  entirely  inadequate. 
In  the  applications  to  the  head  ten  or  twelve  cells 
were,  as  a  rale,  considered  quite  sufficient.  Beneficial 
results  were  often  seen  to  follow  such  mild  treatment, 
it  is  true,  and  it  was  seldom  that  more  was  attempted, 
but  that  the  dose  of  electricity  thus  obtained  was  ex- 
ceedingly slight,  and  far  more  inefficient  than  was  then 
supposed,  can  be  readily  demonstrated.  The  cephalic 
electrode  was  a  broad,  thick  sponge,  while  the  other, 
applied  generally  to  the  pit  of  the  stomach,  was  of 
sponge  also,  but  much  smaller.  The  resistance  thus 
offered  is  necessarily  very  great,  and  if  the  milliam- 
peremeter  is  used,  it  will  be  found  that  the  actual 
quantity  of  electricity  passing  through  the  body  of  the 
patient  hardly  exceeds  six  or  seven  milUamperes. 
Now,  to  use  a  cuiTent  of  only  this  strength  in  appli- 
cations to  the  nerve-centres  is,  as  a  rale,  little  more 
than  child's  play,  and  I  make  this  assertion  in  remem- 
brance of  the  fact  that  I  formerly  advocated  the  effi- 
ciency of  currents  even  milder  than  this.  Sometimes 
benefit  may  undoubtedly  acciTie  from  these  very  mild 
applications,  but  I  have  for  so  long  a  time  observed 
the  effects  of  a  bolder  line  of  treatment  that  I  have  no 
hesitancy  in  advocating  it  in  preference  to  former 
methods. 

In  place  of  a  current  strength  of  five  or  six  milliam- 
peres,  substitute  one  of  twenty,  and  the  superiority  of 
results  will  soon  become  manifest.     But  if,  by  the 

method  in  common  use,  ten  ordinary  cells,  in  the 
14 


210  NERVOUS   EXHAUSTION. 

treatment  of  the  head,  deflect  the  needle  but  about  six 
degrees,  it  would  take  some  fifty  cells  to  give  a  strength 
of  thirty  milliamperes,  and  few  physicians  have  any 
such  number  at  command  as  that.  For  this  purpose 
the  electrodes  should  be  as  large  as  possible — that  is 
— broad,  and  flat  or  curved  according  to  the  part  of  the 
body  to  which  they  are  applied,  but  with  little  bulk. 

With  electrodes  such  as  these  and  a  series  of  twenty 
Leclanche  cells,  a  current  of  thirty  or  more  milliam- 
peres can  readily  be  obtained  in  applications  from 
the  head  to  the  solar  plexus.  Forty  cells  would  there- 
fore give  sixty  milliamperes,  an  intensity  of  current 
seldom  necessary  to  give  in  central  galvanization. 

In  making  these  strong  applications  to  the  brain 
there  is  an  element  of  danger  which  cannot  be  em- 
phasized too  strongly,  and  that  is,  the  possibility  and, 
indeed,  the  probability,  considering  the  utterly  hap- 
hazard way  in  which  electricity  is  too  frequently  used, 
of  the  current  becoming  suddenly  broken 

Even  with  very  weak  currents  apphed  to  sensitive 
nerves,  or  to  the  head,  interruptions  are  as  a  rule  un- 
desirable, and  when  strong,  as  indicated  by  a  deflection 
of  the  needle  of  twenty  or  more,  they  may  painfully 
aggravate  the  very  symptoms  that  you  are  endeavor- 
ing to  allay. 

We  cannot  approximate  the  relative  dose  of  electric- 
ity for  different  ages  as  accurately  as  we  can  that  of 
drugs.  This  observation,  however,  will  be  found  to 
be  uniformly  correct:  The  very  young  bear  propor- 
tionately very  much  stronger  currents  than  adults.  A 
child  of  three,  who  should,  according  to  rule,  tolerate 
only  about  one  -fifth  the  adult  dose  of  any  powerful  drug, 
will  easily  bear  one-third  the  adult  dose  of  electricity. 

Old  people  bear  stronger  cun*ents  than  those  in  mid- 
dle life;  it  is,  indeed,  quite  astonishing  to  observe  the 


HYGIENE  OF  NERVOUS  EXHAUSTION. 


211 


very  marked  insusceptibility  of  some  very  old  people 
to  electricity,  due  in  some  measure,  perhaps,  to  blunted 
sensibility,  but  in  a  higher  degree  to  a  loss  of  conduc- 
tibility  of  the  tissues,  and  especially  the  skin.  It  will 
not  answer,  liowever,  to  presume  too  much  in  the  ap- 
plication of  electricity  to  the  old  on  account  of  this 


Fio.  1. 


apparent  insusceptibility,  as  it  is  not  unconmion  to 
meet  with  patients  advanced  in  years  who,  wliile  they 
may  feel  the  ajJpHcation  of  a  certain  strength  of  cur- 
rent but  httle  at  the  time,  yet  are  exceedingly  suscep- 
tible to  its  secondary  effects. 

I  illustrate  in  Fig.  1  tlie  i)rocess  which  has  given  me 
most  satisfaction   in  the  galvanic  treatment  of  the 


212  NERVOUS  EXHAUSTION. 

central  nervous  system,  not  only  in  neurasthenic  cases, 
but  in  various  other  forms  of  nervous  disease. 

The  hair  being  thoroughly  wet,  a  light  ^vire -gauze 
helmet,  lined  with  some  soft,  conductiag  material,  is 
fitted  as  accurately  as  possible  to  the  head.  To  this  is 
attached  the  positive  pole,  while  the  negative  is  ap- 
phed  to  the  pit  of  the  stomach,  and  a  current  passed 
varying  according  to  the  disease  and  individual  idio- 
syncrasies from  five  to  fifty  miUiamperes. 

It  may  seem  an  easy  tiling  to  make  use  of  central 
galvanization  satisfactorily,  but,  Uke  most  easy  things, 
its  efficient  use  demands  knowledge,  care,  and  some 
experience,  all  of  which  are  within  easy  reach  of  those 
who  desire  to  utilize  the  method.  The  wide  area 
which  this  helmet-electrode  covers  lessens  by  just  so 
much  the  resistance  to  be  overcome,  and  enables  us 
to  pass  through  the  head  a  current  of  many  miUiam- 
peres, without  pain  or  other  ill  results.  To  this  end, 
however,  the  electrode  nmst  be  made  to  adjust  itself 
accurately  to  every  inequality  of  surface,  otherwise  a 
painful  concentration  of  current  will  be  felt  at  various 
points,  and  the  efficacy  of  the  apphcations  interfered 
with.] 

Massage. — An  excellent,  though  not  indispensable 
aid  to  the  treatment  of  neurasthenia  in  women  who 
are  bedridden,  or  who  are  kept  in  bed  for  a  time,  is 
massage  or  systematized  rubbing  and  manij)ulation. 
This  is  performed  in  four  general  ways.  The  ordinary 
and  popular  method  of  nibbing  down  patients  is  not 
massage,  nor  any  approximation  to  it,  and  vviU  not 
produce  the  effect  of  massage. 

1st.  Simply  pinching  the  skin.— This  can  be  done 
thoroughly  over  the  extremities  and  trunk.  It  is  not, 
to  the  majority  of  patients,  a  painful  process;  but,  like 


HYGIENE  OF  NERVOUS  EXHAUSTION.       213 

all  the  operations  of  this  natm-e,  it  may  be  at  first 
somewhat  disagi'eeable  to  the  hysterical  and  hypera^s- 
thetic.  By  a  little  practice  it  soon  becomes  positively 
agreeable. 

2d.  Pinching  the  muscles. — This  is  done  with  both 
hands,  which  grasp  deeply  and  seize  as  much  as  possi- 
ble of  the  muscular  tissues.  On  the  bowels  this  mode 
is  excellently  adapted  for  dyspepsia,  constipation,  and 
liver  disorders. 

3d.  Tapping  and  beating  or  percussion.— The  body 
may  be  gentle  hammered  with  a  pleximeter,  or  with 
tile  fingers,  or  with  the  whole  hand.  Various  instiTi- 
mental  devices  are  employed  for  this  pm-pose.'  When 
this  hammering  is  properly  done,  it  sends  vibrations  at 
a  distance  from  the  point  touched;  not  only  does  it 
stimulate  the  skin  and  the  muscles  directly  beneath  the 
hands  or  fingers,  but  the  most  remote  parts  of  the 
body  receive  the  transmitted  impression,  both  directly 
and  reflexly.  This  part  of  the  process  is  usually  very 
grateful  to  patients. 

4th.  Passive  movements  of  the  joints. — All  the 
joints,  great  and  small,  from  the  fingei*s  to  the 
shoulder  and  hip,  are  removed  backward  and  forward, 
and  rotated,  each  a  number  of  times.  In  paralysis, 
this  process  has  long  been  popular  and  rightly  so,  for 
better  than  almost  any  other  treatment,  it  tends  to 

'Of  tlH'H(!  (l('vi('<'s,  Dr.  <ir;ili;iiii  thus  n-iiiarkH:  "Percussion 
••;m  b»?  pcrforiiu'd  ill  half  a  <lo/.cii  (lifTcrfiit  ways  with  the  hands 
and  fnii^ers,  varyiiii^  in  force  and  rai>idity.  I  have  recently  had 
tw(»  india-rubber  air-balls,  s<'eurely  fastened  on  tlie  ends  of  whale- 
bone handles,  for  this  purpose.  Jialls  two  inches  in  diameter  and 
handles  eleven  inches  lonj^,  are  most  suitable.  They  work  most 
luhnirably.  as  one  jjets  the  springe  of  the  whalel)one  with  tlie  re- 
bound of  the  balls,  thus  ^ainin^;  ^reat  rapidity  of  motion,  with 
easily  varying'  intensity.  It  takes  conaiderable  practice  to  become 
expert  iu  using  them." 


214  NERVOUS    EXHAUSTION. 

prevent  the  stiffness  and  immovability  that  so  often 
follow  neglected  paralysis.  But  in  these  functional 
nervous  affections,  signal  benefit  can  also  be  derived 
from  this  manipulation. 

The  effects  of  massage,  when  carried  out  in  the 
manner  above  described,  are  nmch  like  the  now  well- 
known  effects  of  general  faradization,  namely:  quick- 
ening and  equalization  of  the  circulation,  general 
sedation  and  disposition  to  sleep,  and  relief  of  pain 
and  of  the  indefinable  nervousness  that  is  so  often 
worse  than  absolute  pain. 

The  science  and  art  of  massage  is  worthy  of  more 
study  than  it  has  yet  received;  the  j)opular  process  of 
gently  superficially  rubbing  the  body,  frequently  with 
all  the  clothes  on,  is  no  substitute  for  genuine  mas- 
sage, any  more  than  the  old  habit  of  playing  with  the 
battery  can  take  the  place  of  systematic  and  skillful 
use  of  the  various  applications  of  electricity.  There 
are  those  who  think  they  have  tried  electricity  when 
they  have  only  held  the  poles  of  a  common  faradic 
machine  in  the  hands;  just  so  there  are  those  who 
think  they  have  tried  massage  when  they  have  only 
been  rubbed  down  like  a  horse,  though  probably  with 
less  care. 

The  operation  of  massage  may  take  all  the  way  from 
fifteen  minutes  to  half  an  hour,  or  even  an  hour.  It 
may  be  used  daily  or  every  other  day,  either  alone  or 
in  connection  with  electrical  treatment,  or  in  alterna- 
tion with  it.  Patients,  after  becoming  accustomed  to 
it,  do  not  dread  the  hour  when  it  is  to  be  used;  but 
are  so  pleased  with  its  sedative  tonic  effects  that  they 
ask  for  and  anticipate  it.  Massage  is  especially  fitted 
for  those  who,  on  account  of  myelasthenia,  or  exhaus- 
tion of  the  spinal  cord,  are  unable  to  take,  without 


HYGIENE   OF  NERVOUS  EXHAUSTION.  215 

fatigue,  any  considerable  amount  of  active  muscular 
exercise.' 

''About  seven  years  ago  Dr.  Mezger  treated  the 
then  Danish  crown  prince  successfully  for  a  chronic 
joint  malady  by  means  of  massage,  which  he  used  in 
a  manner  original  to  himself,  and  in  accordance  with 
the  teachings  of  physiology  and  pathological  anatomy. 
When  the  prince  got  well,  he  sent  a  young  physician 
to  Amsterdam  to  study  Dr.  Mezger's  method  of  ap- 
plying it,  and  soon  after,  many  old  as  well  as  young 
physicians  visited  the  clinic  of  Mezger,  and  they  all 
agi-eed  that  the  so-caUed  massage,  used  in  Mezger's 
manner,  and  according  to  the  indications  which  a 
very  large  experience  has  enable  him  to  point  out,  is  a 
most  worthy  agent  in  various  affections  of  the  joints, 
besides  in  inflammations  and  neuroses.  They  con- 
sider that  credit  is  due  to  Mezger  for  having  improved 
massage  in  a  physiological  manner,  and  for  having 
brought  it  to  be  acknowledged  as  a  highly  valuable 
method. 

A  few  extracts  from  the  very  excellent  and  compre- 
hensive report  on  massage,  in  Schmidt's  Jahrhilchcr, 
Vol.  IfiG,  1875,  will  show  the  estimation  in  which  it  is 
held  by  some  of  the  first  German  physicians.  The 
reporter  begins  by  saying  that  "  it  is  but  recently  that 
massage  has  gained  an  extensive  scientific  considera- 
tion, for  it  has  passed  out  of  the  hands  of  rough  em- 
l»irics,  into  those  of  scientific,  cultivated  physicians; 
and,  upon  the  ground  of  the  results  of  recent  scientific 

'  Dr.  Douglas  Graham,  of  Boston,  has  published  a  very  interest- 
iti(;  pamphlet  (111  "  Tlie  History  t)f  Massn^je,"  from  vliich  it  ap- 
pc'ars  tliat  iriassau'e  really  dates  hack  to  Hippocrates  aial  ('elsiis, 
.-iiid  was  first  made  scientific  hy  Liiitr,  of  S\ve<ieii.  in  1H1;{.  Within 
a  few  years  interest  in  the  suljject  lias  i>ecn  revived  by  the  elTorta 
of  Dr.  Mezger,  uf  Amsterdam. 


216  NERVOUS    EXHAUSTION. 

investigations,  it  has  been  cultivated  into  an  improved 
therapeutical  system.  The  Danish  physician,  Mezger, 
has  won  the  merit  of  having  made  massage  in  its 
entirety  a  special  branch  of  the  art  of  medicine." 
Then  follows  a  hst  of  forty  articles  on  massage,  by  a 
score  of  authors,  mostly  Scandinavian,  ouly  one  being 
American.  The  manner  of  using  massage  and  its 
physiological  action  are  next  described;  and,  after 
this,  the  results  of  massage  in  similar  cases,  treated  by 
different  authors,  are  grouped  and  compared—  so  many 
cured,  so  many  benefited,  and  so  many  not  reUeved. 
The  report  concludes  by  saying  that,  ' '  if  massage  is 
to  be  of  any  use,  it  ought  to  be  apphed  by  those  who 
are  absolutely  physicians;  for  the  brilliant  results 
which  have  just  been  cited  depended  upon  an  exact 
knowledge  of  anatomy  and  physiology,  and  also  upon 
recent  progress  in  medical  and  surgical  pathology, 
which  enabled  the  operators  to  make  an  accurate  diag- 
nosis. A  very  impoi-tant  part  of  the  qualifications 
necessary  for  the  effectual  performance  of  massage 
depends  upon  the  physical  qualities  of  the  manipula- 
tors;'they  require  strength  of  hands  and  fingers,  en- 
durance and  elasticity,  which  every  physician  does  not 
possess;  and  herein  lies  the  danger  that  the  practice 
of  massage  will  pass  into  the  hands  of  the  laity,  who, 
again,  have  not  the  other  requisites,  viz.,  medical 
knowledge  " '  (Graham). 
Lomi-Lomi. — My  friend  Dr.  N.  B.  Emerson,  a  native 

'  Prof.  Von.  Mosengeil,  of  Bonn,  speaking  of  massage,  says: 
"  Its  value  must  be  recognized  ;  but  it  is  not  adapted  for  every- 
day use  by  every  physician;  nor -will  it  be  much  used  in  hospitals, 
for  lack  of  time.  The  best  results  will  be  obtained  by  the  few 
who  bring  to  its  use  abundance  of  time,  patience,  skill  and 
strength.  Specialists,  therefore,  will  probably  get  the  most  satis- 
factory results  from  it.  ("Arch.  f.  klin.  Chirurg.,"  XIX.,4, 1876.) 
— (Graham.) 


HYGIENE  OF  NERVOUS  EXHAUSTION.  217 

of  the  Sandwich  Islands,  pubHshed  in  Appleton's 
Journal^  October,  1870,  a  very  interesting  article  on 
lomi-lomi.  He  states  that  there  are  two  kinds  of  lomi- 
lomi,  which  is  their  form  of  massage.  He  says  that  it 
is  divided  into  two  kinds,  general  and  special;  that  is, 
general  for  the  whole  body,  and  special  for  certain 
parts,  and  is  usually  performed  by  eldeily  and  experi- 
enced women.  It  consists  in  kneading,  squeezing,  and 
rubbing;  and  in  degree  may  vary  from  the  tenderest 
caress  to  the  severest  grip. 

To  perform  this  operation,  or  to  have  it  performed 
for  one,  is  one  of  the  highest  compliments  a  host  can 
pay  to  a  guest.  Usually,  severe  pain  is  avoided, 
although  at  first  the  operation  may  be  somewhat  pain- 
ful; but  it  becomes,  in  time,  exceedingly  agreeable. 
In  some  cases,  the  natives  lie  down,  and  aUow  children 
to  walk  over  them. 

The  Sandwich  Islanders  are  great  swimmers,  as  we 
all  know;  and  when  one  of  them  becomes  weary, 
while  swimming,  the  others  rub  him  thoroughly  while 
in  the  water. 

Dr.  Emerson  suggests  that  perhaps  tlie  superior 
physique  of  the  better  class  of  Sandwich  Islanders 
may  be  in  part  due  to  the  frequent  use  of  this  lomi- 
lomi,  which  is  substantially  what  we  mean  by  mas- 
sage, as  that  term  is  now  used  in  science. 

General  faradizatioli,  when  properly  and  thoroughly 
performed  over  the  whole  body,  or  even  over  the  trunk 
alone,  really  unites  the  advantages  of  massage  in  a 
considerable  degree  with  the  advantage  of  electricity. 
In  the  practice  of  many  physicians  general  faradiza- 
tion is  carried  out  in  such  a  way  that  it  becomes  but  a 
series  of  local  faradizations;  this  method  is  more  un- 
l>leasant  foi-  the  patient  and  far  less  satisfactory  in  all 
respects  than  its  thorough  employment  as  directed  in 


218  NERVOUS  EXHAUSTION. 

our  original  writings  on  the  subject.  As  I  now  use 
this  method  in  many  cases,  very  sKght  undressing  of 
the  patient  is  needed. 

Hydro-Therapeutics. — At  the  present  time,  the 
method  of  treatment  by  douches  to  the  spine  and  back 
of  the  neck  is  growing  in  favor.  In  Paris,  as  I  saw  at 
the  water-cure  estabhshment,  a  very  fine  spray  is  used, 
sent  with  such  force  that  the  water,  though  cold,  ap- 
peared to  be  hot,  and  could  be  borne  by  the  hand  only 
for  a  few  moments.  This,  appHed  to  the  spine,  is  a 
very  powerful  means  of  counter- irritation.  The  ap- 
plication also  of  compresses,  cold  or  hot,  and  of  wet 
sheets,  with  dry  ones  wrapped  over,  when  properly 
apphed  and  guided  with  special  reference  to  the  needs 
of  each  case,  are,  hkewise,  of  the  highest  service. 
Sometimes,  compresses  of  wet  cloths  wrung  out,  and 
thick  dry  ones  around  them,  applied  to  the  stomach 
and  liver  and  genitals,  and  kept  for  some  time,  are 
most  excellent  means  of  relief. 

This  mode  of  treatment  has,  however,  been  over- 
rated, for,  valuable  as  it  is,  it  cannot  and  does  not 
alone  cure  neurasthenia;  many  of  my  cases  have  tried 
it,  in  some  instances,  for  years.  Water  treatment, 
like  all  other  excellent  means  of  treatment,  has  been 
greatly  misused.  If  used  at  all  for  nervous  exhaus- 
tion, it  must  not  be  in  the  old,  but  in  the  new  style, 
adapted  to  the  modern  constitution,  and  all  cases  can- 
not be  treated  in  the  same  way. 

Turkish  and  Bussian  Baths. — The  now  popular 
Turkish  and  Eussian  baths  are  among  the  auxiliary 
means  of  relief  for  these  cases  that  can  be  recom- 
mended; but  they  cannot  be  indiscriminately  recom- 
mended, and  they  cannot  be  expected  to  cure  the 
majority  of  cases,  particularly  those  of  long  standing. 

In  a  very  considerable  number  of  instances,  they 


HYGIENE  OP  NERVOUS  EXHAUSTION.  219 

seem  to  do  harm.  One  trouble  is,  that  these  baths  are 
ovei-used;  patients  stay  too  long  in  the  hot  room. 
These  baths,  like  other  hygienic  measures,  mus!;  be 
adapted  to  the  temperament,  the  constitution,  the 
stage  of  the  disease,  far  more  than  they  are  now,  in 
order  to  make  them  of  general  use  for  neurasthenic 
sufferers.  I  continually  see  patients  who  have  tried 
them  and  who  have  been  injured,  the  fault  being  not 
so  much  in  the  principle  of  the  baths  as  in  the  way  in 
which  they  are  used  or  abused,  I  am  never  willing 
to  hav^e  a  very  nervous  patient  take  these  baths  unless 
they  are  closely  watched  to  see  that  they  do  not 
remain  in  too  long  and  become  exhausted. 

Heat  and  Cold. — The  local  applications  of  both  heat 
and  cold  are  very  valuable  in  some  phases  of  nem-as- 
thenia.  The  ice  bags  and  the  hot- water  bags  are  use- 
ful in  applications  to  the  spine  and  to  any  painful  part. 
In  some  cases  a  cold,  in  others  a  warm  apphcation 
seems  to  be  most  satisfactory.  Bags  of  ice,  or  ice 
wrapped  in  a  towel,  applied  to  the  back  of  the  neck 
and  to  the  vortex  are  means  of  rehef  and  excellent 
adjuvants  to  the  prolonged  treatment  of  these  cases. 
With  these,  as  with  all  remedies,  there  is  danger  of 
over  use.  Cold,  in  the  form  of  ice  especially,  may  be 
applied  too  l<jng.  When  used  on  delicate  females, 
this  should  bo  wat(:hcd  witli  care. 

Alternations  of  heat  and  cold — heat  for  a  moment, 
tlien  cold  for  a  moment— are  excellent  means  of  local 
treatment. 

Jji.iittives  and  Cailiartics. — A  very  old  method  of 
treatment  is  by  cathai-tics.  This  routine  plan  of  com- 
bating diseases,  «'Si)0(ially  those  chronic  diseases  asso- 
ciated with  debility,  is  at  present  so  mipopular  that 
one  needs  to  pray  for  com'age  before  attempting  to 
revive  it.     I  am,  however,  convinced  from  positive 


220  NERVOUS  EXHAUSTION. 

experience — complicated,  I  admit,  with  the  sources  of 
error  that  attend  all  of  our  therapeutical  experiments 
— that  in  many  cases  of  neurasthenia  and  allied  dis- 
orders it  is  wise  to  begin  the  treatment,  whatever  it 
may  be,  by  acting  upon  the  bowels  by  some  cathartic 
medicine;  and  to  repeat  this  procedure  at  intervals 
during  a  course  of  other  medication.  Of  themselves 
alone,  unaided  by  sedatives  or  tonics,  they  would 
rarely,  if  ever,  cm'e  a  case  of  neurasthenia;  indeed, 
there  are  cases  where  they  cannot  be  used  at  all.  The 
philosophy  of  active  catharsis  is  somewhat  complex, 
the  freeing  of  the  bowels  and  the  unloading  of  the 
hver  being  not  always  or  necessarily  the  most  impor- 
tant. Cathartics  act  by  counter-irritation;  they  irri- 
tate the  Hning  membrane  of  the  intestines  as  truly  as 
a  fly-plaster  does  the  back,  and  the  benefit  that  follows 
their  use  must  be  in  part  the  reriex  results  of  this  irri- 
tation. 

One  reason  for  the  present  unpopularity  of  certain 
old  methods  of  treatment,  as  laxatives,  cathartics,  and 
counter-irritation  of  various  Iduds,  is  that  they  have 
not  been  adapted  to  the  modern  constitution,  which 
will  not  bear  and  does  not  need  such  large  quantities 
of  medicine,  or  as  vigorous  treatment  or  hygiene,  as 
the  ancient  constitution.  Physicians  forget  that 
whatever  the  remedy  used,  it  should  be  fitted  to  the 
civilized  constitution  as  it  appears  in  this  latter  part  of 
the  nineteenth  century.  Various  remedies  used  by 
our  fathers  with  satisfaction  and  success  are  as  good 
now  as  they  ever  were,  provided  they  are  used  less 
vigorously  and  violently.  It  is  as  unscientific  to  give 
children  the  same  doses  that  are  given  to  adults,  as  to 
treat  the  nervously  exhausted  sufferers  of  the  present 
time,  and  especially  in  this  country,  just  as  om'  fathers 
were  treated.    Laxatives  and  purges  are  as  valuable 


HYGIENE  OF  NERVOUS  EXHAUSTION.  221 

as  they  "were  one  hundred  years  ago,  if  they  be  rightly 
used,  that  is,  modified  to  the  greater  nerve  sensitive- 
ness of  our  generation. 

In  treating  neurasthenic  conditions  by  cathartics  or 
laxatives,  these  two  principles  are  to  be  borne  in  mind: 

First.  That  the  dose  should  be  small,  just  sufficient 
to  cause  one,  or  but  few  discharges  with  slight  pain, 
or  none  at  all. 

Secondly.  To  keep  up  their  action  by  intervals  for  a 
considerable  time. 

A  prescription  that  I  often  use  but  variously  modify, 
according  to  individual  peculiarities,  is  the  following 
euonymin  compound: 

Euonymin 0.06  grams 

Hydrastis, 

Aloes  Socot., 

Hyoscyamus, 

PodophylUn aa  0.03  grams 

For  one  pill.  Dose  one,  two,  or  three,  according  to 
the  susceptibility  of  the  patient. 

Counter-irritation,  when  intelligently  and  judiciously 
used,  with  proper  modification  to  the  peculiarities  of 
the  modern  constitution  and  to  individual  idiosyncrasy, 
is  as  good  a  remedy  for  disease  as  it  ever  was;  and  all 
the  progi'ess  that  has  been  made  during  the  past  half 
century  has  not  displaced,  and  no  immediate  progress 
in  the  future  threatens  to  displace  it  in  the  treatment 
of  many  forms  of  nervous  disease. 

The  prejudice  in  the  popular  mind  against  counter- 
in-itation  has  the  same  basis  as  the  i)rejudice  against 
the  use  of  electricity,  or  calomel,  or  water — namely, 
that  it  is  so  good  that  it  has  been  over-used  and 
abused ;  hence,  the  reaction  against  this  mode  of  treat- 
ing disease.     It  is  because  calomel,  and  bleeding,  and 


222  NERVOUS  EXHAUSTION. 

electricity,  and  opium,  and  alcohol,  and  counter-irrita- 
tion were  so  successful  in  so  large  a  variety  of  cases 
that  they  have  been  so  much  prescribed;  the  positive 
and  satisfactory  results  obtained  froai  these  remedies 
tempted  physicians  to  depend  exclusively  upon  them, 
to  the  neglect  of  other,  and  as  we  now  know,  equally 
valuable  remedies. 

For  neurasthenia  and  allied  disorders,  counter-  irrita- 
tion alone  is  of  the  highest  service,  and  can  be  used 
■without  causing  severe  pain,  or  even  discomfort. 

Small  Blisters. — One  of  the  most  convenient  and 
successful  methods  of  counter-imtating  in  fmictional 
nervous  maladies  is  by  small  bhsters,  frequently  re- 
peated; whenever  the  symptom  of  tenderness  in  any 
part  of  the  spine  appears,  whatever  accompanying 
symptoms  there  may  be,  a  succession  of  blisters  so 
smaU  as  to  cause  Uttle  or  no  annoyance,  is  always  in- 
dicated, and  will  be  sure  to  help  the  patient,  even 
though  various  other  medication  is  used  at  the  same 
time;  indeed,  it  is  one  of  the  advantages  of  counter- 
irritation,  that  it  can  be  used  in  conjunction  with  any 
or  all  other  forms  of  treatment.  A  blister  composed 
of  a  strip  of  rubber  adhesive  plaster,  and  covered  in 
the  centre  with  a  very  small  quantity  of  cantharides 
ointment,  will  stay  where  it  is  put,  and  will  not  cause 
distress.  For  appUcation  to  the  spine,  a  plaster  of  one 
inch  in  length  and  half  an  inch  in  breadth  is  usually 
sufficient,  and  its  comparative  painlessness  will  sur- 
prise those  who  are  wont  to  submit  to  the  enormous 
bhsters  that  were  formerly  used.  Indeed,  one  of  the 
great  practical  difficulties  in  the  recommendations  of 
bhsters  to  patients  is  the  remembrance  of  what  they 
have  suffered,  or  seen  others  suffer,  from  the  fearfully 
large  applications  that  were  formerly  prescribed  in 
various  diseases.     This  prejudice  can  be  removed  by 


HYGIENE   OF  NERVOUS  EXHAUSTION.  223 

stating  the  facts,  and  by  explaining  that  bUsters,  hke 
all  other  modes  of  treatment,  can  be  adapted  to  the 
modem  constitution,  and  to  functional  nervous  dis- 
ease; and  that  when  used  in  this  way,  they  are  not 
objects  of  dread,  but,  after  a  fair  trial,  will  be  eagerly 
sought  after  on  account  of  the  delightful  relief  they 
afford. 

In  regard  to  the  use  of  blisters  as  here  recommended, 
patients  and  physicians  should  be  disabused  of  two 
errors : 

1.  That  they  relieve  and  cure  by  virtue  of  their  de- 
pleting effect.  The  quantity  of  serum  that  is  ab- 
stracted by  one  of  these  small  blisters  is  very  trifling, 
and  in  no  way  proportioned  to  the  good  they  accom- 
phsh. 

These  blisters  act  reflexly  through  the  local  irrita- 
tion that  they  excite,  analogously  to  the  actual  cau- 
tery. 

If  the  object  were  the  local  abstraction  of  blood,  it 
would  be  nmch  better  to  use  wet  cupping  or  the 
artificial  leech. 

2.  To  get  permanent  effects  from  them,  they  should 
be  many  times  repeated;  a  single  application  gives 
but  transient  relief,  grateful  and  satisfactory  as  that 
may  be.  Patients,  and  even  physicians,  often  suppose 
that  the  philosophy  of  blistering  is  to  draw  out  as 
much  blood  or  seinim  as  possible,  and  by  a  single  and 
severe  apphcation,  which  generally  is  not  to  be  re- 
peated. 

In  acute  inflammatory  diseases,  this  principle  may 
come  in,  but  not  in  tlie  conditions  we  are  describing. 

Hence  the  necessity  of  making  the  bhsters  so  small 
as  to  be  of  the  least  possible  annoyance  to  the  delicate 
and  nervous  sufferer,  who  already  has  distress  enough 
to  endure. 


224  NERVOUS  EXHAUSTION. 

The  blisters  used  in  these  functional  disorders  should 
not  only  be  short  and  narrow,  but  should  be  placed 
perpendicular  to  the  spine  rather  than  across  it,  thus 
interfering  as  little  as  possible  with  the  movements  of 
the  muscles  of  the  back.  Thus  prepared  and  applied, 
they  do  not,  as  a  rule,  need  to  be  dressed  at  all;  they 
can  be  kept  on  until  they  dry  up  and  fall  off  them- 
selves, when  another  can  be  safely  put  on  in  the 
same  place.  The  relief  which  they  give  is  not  usually 
felt  until  they  begin  to  itch;  indeed,  for  the  first  day 
or  two,  patients  sometimes  declare  that  they  aggravate 
the  symptoms. 

3.  To  depend  on  them  alone  for  the  cure.  They  are 
adjuvants  only  to  constitutional  treatment,  and  in 
many  cases  they  are  not  indicated  at  all.  I  should 
never  think  of  treating  a  case  by  blisters  only  or 
mainly.  The}''  are  but  pai-t  of  the  team  that  is  to 
draw  the  load. 

The  pecuUarities  of  my  mode  of  bhstering,  then,  are 
these  four: 

1.  The  use  of  a  very  small  surface — very  much  smaller 
than  has  usually  been  recommended  or  employed. 

2.  The  use  of  a  very  small  quantity  of  cantharides 
ointment.  This  I  scatter  at  points  on  the  blister.  The 
blisters  sold  in  shops  do  not  serve  my  purpose.  They 
are  too  strong;  they  cause  the  plaster  to  rise  up  over 
the  blister  and  fall  off,  which  is  precisely  what  is  not 
wanted.  I  always  prepare  my  blister  plasters  myself;  I 
never  prescribe  them;  for  if  I  do,  I  do  not  get  satisfac- 
tion. The  patients  are  irritated,  annoyed,  and  get  a 
prejudice  against  the  bUsters  which  tends  to  discourage 
them,  and  they  do  not  get  the  results;  they  cannot  get 
the  results  by  the  blisters  that  are  made  in  the  shops 
unless  they  are  made  over  again  or  modified  for  this 
special  purpose. 


HYGIENE  OF  NERVOUS  EXHAUSTION.  225 

3  The  retention  of  the  bhster  for  several  days,  or 
until  it  falls  off.  By  this  means  irritation  is  kept  up 
which,  properly  managed,  is  not  annoying  even  to  the 
sensitive  girl,  and  which  brings  a  relief,  both  more 
grateful  and  incompai-ably  more  permanent  than  the 
accepted  method  of  using  blisters. 

4.  Repetition  from  tin)e  to  time  with  a  view  to  per- 
manent effects.  If  large  blisters  were  used,  the 
patients  would  not  l)ear  this;  and  it  is  well  that  they 
should  not,  for  they  would  be  likely  to  be  injured  more 
than  benefited  by  such  severe  treatment. 

MUd  Cautery. — Another  .very  old  remedy,  but  as 
good  as  it  is  old,  where  it  is  properly  used,  is  the  actual 
or  (jalvano- cautery. 

There  is  among  the  people,  and  even  in  the  profes- 
sion, a  prevalent  notion  that  tlu^  apphcation  of  the 
actual  cautery  is  a  very  painful  procedure.  This  false 
idea  has  been  fostered  with  the  public  on  account  of 
the  supposed  sufferings  of  cei'tain  proniinent  persons, 
like  Charles  Sunnier,  and  Clara  Morris  the  actress, 
from  this  treatment.  The  lectures  of  BrovvnSequard, 
referring  to  this  subject,  assisted  in  confirming  this 
impression,  and  the  newspaper  accounts,  in  every  ])os- 
sible  way,  have  stimulated  and  strengthened  the  belief 
that  it  requires  the  courage  of -a  hero  to  submit  with- 
out etherization  to  the  operations  of  the  actual  cau- 
tery. The  real  scientific  truth  on  tliis  matter  is,  that 
the  cautery,  as  it  can  bo  used  with  modern  appliances, 
as  the  galvano-cautery  or  Pacpielin's  apparatus,  and  is 
used  by  those  who  understand  it,  is  not  specially  pain- 
ful, even  to  the  most  delicate  woman.  The  i)ain  is  in 
the  idea  of  the  thing— in  tiie  expectation,  and  not  in 
burning.  Any  one  who  has  had  a  sensitive  tooth  filled 
has  suffered  ten  times  more  than  one  who  has  submit- 
ted to  a  cautery  operation,  if  ])ro]»edy  ixuformed.  I 
15 


226  NERVOUS  EXHAUSTION. 

speak  of  this  point  particularly,  because  the  mild  cau- 
tery is  an  agent  of  such  great  therapeutic  power.  This 
mode  of  treatment,  like  the  blisters  ah-eady  referred 
to,  must  be.  and  now  can  be.  modified  and  adapted  to 
the  sensitive  modern  constitution.  It  is  one  of  the 
great  remedies  that  stands  the  test  of  time  and  large 
experience. 

Everything  depends  on  the  way  in  which  the  cau- 
teiy  is  applied.  It  can  be  used  in  such  a  way  as  to 
cause  scarcely  any  pain  or  annoyance:  so  that  those 
who  have  had  one  application  are  willing  and  glad  to 
have  succeeding  a|)pUcations,  and  ask  for  them  as 
people  would  ask  for  an  application  of  electricity,  or  a 
dose  of  massage.  I  am  convinced,  from  my  own  ex- 
perience, that  the  occasional  use,  or  in  some  cases, 
perhaps,  the  frequent  use  of  a  verji  mild  cautery  indeed 
— so  mild  as  not  to  be  annoying  to  the  most  sensitive 
girl — is  far  more  etficacious  than  the  usual  method  of 
administering  this  remedy. 

This  is,  indeed,  in  ha)'mony  with  the  method  of 
blistering  above  described.  In  cases,  not  a  few,  the 
apphcation  of  a  strong  cautery  is  followed  by  a  depres- 
sion which  lasts  for  a  day  or  two.  This  depression  is 
not  always  a  bad  sign;  it  occurs  in  those  who  are 
greatly,  very  greatly  benefited  by  the  cautery:  but  in 
some  cases  it  is  discouraging  to  the  patient,  and  indi- 
cates that  the  cautery  has  been  used  too  often,  or  too 
severely.  In  all  cases,  this  depression,  as  well  as  the 
pain,  can  be  avoided  by  a  proper  arrangement  of  the 
dosage  of  the  cautery. 

The  slight  scars  made  by  any  counter-irritants  to 
cases  of  this  kind  quickly  heal,  and  even  the  stains 
soon  disappear  as  a  rule;  for  it  is  a  peculiarity  of  neu- 
rasthenic constitutions  that  wounds  heal  quickly — 
more  quickly,  as  I  judge,  than  in  the  average  consti- 


HYGIENE   OF  NERVOUS  EXHAUSTION.  227 

tution.  In  some  cases,  the  irritation  heals  altogether 
to^  quickly,  so  that  it  is  necessary  to  repeat  it  quite 
frequently.  As  I  understand  it,  these  woimds  heal 
quickly  in  these  persons,  for  the  same  reason  that  they 
do  not  have  inflammations,  or  are  not  Uable  to  febrile 
diseases. 

Metalloscopy  or  Metal  Tlierapeutics. — While  in  Paris, 
Charcot  gave  me  every  opportunity  to  observe  all  his 
experiments,  not  only  in  the  department  of  metallo- 
scopy, but  in  trance,  and  the  conclusions  which  I  have 
reached  from  the  observations  then  and  there  made, 
and  from  my  own  experiments,  and  from  the  htera- 
ture  of  the  subject,  are  as  follows: 

1.  Results  far  more  interesting  and  informing,  both 
in  a  physiological  and  in  a  therapeutical  sense,  have 
been  obtained  where  the  experiments  were  made  in 
such  a  way  as  to  make  it  absolutely  certain  that  the 
only  factor  in  producing  the  results  was  merely  sub- 
jective—i)ie  mind  of  the  patient  acting  upon  the  body. 
It  is  also  established  that,  under  any  influence  or  mode 
of  treatment  calculated  to  act  on  the  emotions  in  any 
way,  it  is  difficult  to  exclude  this  subjective  element  of 
error,  which  comes  from  the  mind  of  the  patient  oper- 
ated upon. 

In  my  own  experiments  in  mental  therapeutics, 
thus  far  published  only  in  abstract,  I  have  established 
the  following: 

First.  By  turning  the  mind  of  the  patient  on  his 
body,  through  any  process  whatever,  as  by  stating  the 
precise  hour  when  recoveiy  will  take  place,  by  apply- 
ing metals  outside  of  the  clothing,  etc.,  it  is  possible  to 
cure  permanently,  as  well  as  very  rapidly,  and  in  some 
cases  instantaneously,  cases  of  long-standmg  fu ac- 
tional nervous  disease. 

Second.  Even  organic  structural  disease  may,  in  the 


228  NERVOUS   EXHAUSTION. 

same  way,  be  relieved  temporarily  more  speedily  and 
satisfactorily  than  by  any  of  our  objective  medication. 
In  any  physiological  or  therapeutic  experiments  or 
measures,  like  the  application  of  metals  or  magnets, 
or  any  very  imposing  proceedings  that  strike  the 
emotions  of  ignorant  or  hysterical  women,  the  pre- 
sumption is,  thousands  to  one,  that  the  result,  what- 
ever that  may  be,  is  subjective  and  not  objective,  and 
this  presumption  must  be  overthrown  before  such  ex- 
periments can  be  received  as  science. 

2.  On  the  other  hand,  the  recent  discoveries  and  in- 
ventions, of  which  the  telephone,  the  phonograph,  the 
audiometer,  and  the  microphone  are  types  and  repre- 
sentatives, have  proved  that  great  results  can  come 
from  changes  in  matter  very  minute  and  far  out  of  the 
range  of  the  senses.  It  is  also  well  known  that  a 
magnet  can  stop  a  watch,  elongate  an  iron  rod,  and 
make  music  in  it.  These  results  so  far  are  in  favor 
of  the  claims  oC  Bui'q,  Charcot,  and  others  in  regard 
to  metals,  magnets,  and  solenoids.  Admitting  that 
the  results  of  some  of  these  experiments  are  absolutely 
proved  to  be  objective,  there  would  be  no  difficulty  in 
giving  at  least  a  general  explanation  on  the  basis  of 
the  now  established  facts  of  physics  and  electro- 
physics.  These  hysterical  and  hystero-epileptic  cases 
are  exceedingly  susceptible,  and  a  very  slight  force, 
subjective,  or  objective,  will  affect  them. 

3.  The  first  presumption — that  the  results  are  sub- 
jective— can  be  overcome  only  by  a  series  of  experi- 
ments on  different  patients,  under  different  circum- 
stances, and  at  different  times,  in  which  all  the  six 
sources  of  error  that  apply  to  all  the  experiments  with 
living  human  beings  have  been  carefully  eliminated. 
The  six  sources  of  error  are  as  follows: — 1.  Unconscious 
deception  on  the  part  of  the  subject  experimented 


HYGIENE   OF  NERVOUS   EXHAUSTION.  229 

on;  2.  Intentional  deception  on  the  part  of  the  subject 
experimented  on;  3.  Intentional  coUusion  of  other 
parties;  4.  Unintentional  coUusion  of  other  parties;  5. 
Chances  and  coincidences:  and,  6.  Phenomena  of  in- 
voluntary life,  the  mind  of  the  subject  operating  on  the 
body  and  producing  results.  To  eliminate  these  en'ors, 
the  subject  experimented  on  must  be  deceived. 

4.  The  reports  of  experiments  made  by  Burq  and 
CHiarcot,  as  they  were  first  made,  and  the  replies  to 
criticisms  upon  them,  contained  no  evidences  what- 
ever that  these  sources  of  en'or  had  been  ehminated. 
It  is  right,  and  scientific,  and  necessary,  therefore, 
that  we  should  assume  that  the  presumption  that  the 
results  were  subjective  had  not  been  overcome.  I 
have  notliing  to  recall  or  modify  of  my  criticisms  on 
these  experiments  in  my  pamphlet  on  that  subject.' 

5.  There  is,  however,  noiv  evidence  of  an  important 
character  that  more  recent  experiments  of  Charcot  and 
several  others  have  been  made  in  such  a  way  as  to 
eliminate  these  sources  of  error;  and  if  the  statements 
of  Charcot  made  to  me  are  accepted,  results  have  been 
obtained  which,  some  of  the  time  at  least,  are  objec- 
tive, and  we  have  so  far  obtained  an  addition  to  physi- 
ological science.  Similar  results  as  those  reported  by 
Charcot  in  hysterical  conditions  have  been  obtained  by 
Dr.  McCall  Anderson,  of  Glasgow,  and,  according  to 
his  own  report,  the  elements  of  error  were  properly 
eliminated  by  the  use  of  false  magnets.  When  he 
used  false  magnets  no  effects  followed;  Charcot  says 
the  same.  More  recently  still.  Dr.  Franz  Miiller,  of 
Gratz,  Germany,  has  published  in  the  Berliner  Klin- 
ische    WockensdiHft,  No.  28,  1870,  a  paper  entitled 

'  I  have  foniiudated  and  dincuHsed  these  six  sources  of  error  in 
<li't;iil  in  njy  paperH  f>n  "  Rxperimonts  with  Liviii;;  Iluiiian 
iJeiiij^s."     "  Popular  8cience  Moutlily,"  Marcli  and  April,  18TU. 


230  NERVOUS    EXHAUSTION. 

Z^ir  Metalloscoirle  unci  Magnetivirkung  bet  Hyster- 
isclien  Ldhmungen,  wherein  he  confirms  the  claims  of 
Burq  and  Charcot  in  regard  both  to  the  action  of 
metals  and  magnets.  Mliller,  unlike  most  of  the  ex- 
perimenters in  this  field,  seems,  according  to  his 
report,  to  be  fully  conscious  of  the  six  sources  of  error, 
though  he  does  not  formulate  them,  and  makes  his 
experiments  accordingly.  Such  reports  help  to  over- 
come the  enormous  presumption  against  these  results 
being  objective. 

6.  The  subject  has,  therefore,  reached  a  stage  where 
it  may  properly  receive  the  attention  of  experts  in  this 
department.  It  is  an  open  question  worthy  of  investi- 
gation, and  waiting  to  be  closed  one  way  or  the  other. 
No  experiments  in  this  department  are  worth  anything 
miless  the  subject  is  all  the  time  deceived.  The  public 
exhibitions  of  Charcot  prove  nothing,  for  they  make 
no  allowance  for  all  the  six  sources  of  error.  Charcot, 
in  conversation  with  me,  declared  that  for  the  scien- 
tific study  of  the  subject  he  depended  on  his  nrivate 
experiments. 

These  questions,  however  settled,  have  apparently  a 
physiological  more  than  a  therapeutical  interest. 
Charcot  has  abandoned  metal  therapeutics  so-called, 
and  regards  his  experiments  merely  as  physiological 
curiosities.  It  is,  however,  not  impossible  that  we 
shaU  find  in  these  processes  an  addition  of  a  certain 
value — perhaps  of  a  greater  value  than  is  now  ap- 
parent, for  relieving  hysteria,  neurasthenia,  and  allied 
states. 

Nitrous  Oxide  ("laughing  gas")  is  recommended 
by  Drs.  Blake  and  Hamilton  {Med.  Record,  Ja,n.  31st, 
1880)  as  a  stimulant  in  neurasthenia.  Daily  inhala- 
tions of  not  less  than  twenty  gallons,  weU  diluted  with 
air,  are  required. 


HYGIENE  OF  NERVOUS  EXHAUSTION.  231 

Philosophy  of  this  Plan  of  Treatment.  —Nerve-Alter- 
atives.— Diseases  of  this  character  are  hable  to  be  re- 
heved  or  cured  by  any  mode  of  treatment,  external  or 
internal,  medical  or  mechanical,  that  is  capable  of  pro- 
ducing a  change  in  the  constitution. 

In  neurasthenia  there  is  no  new  substance,  no 
entity,  no  poison  introduced  into  the  system;  there  is 
simply  bad  nutrition — a  poverty  of  nerve  force — and, 
we  may  suppose,  instability  and  abnormal  movements 
of  the  ultimate  particles  of  the  living  matter. 

Now  anything  that  alters  the  nutrition,  deflects 
these  motions,  giving  them  a  different  direction  from 
what  they  already  have,  may  exercise  a  relieving  if 
not  a  curative  effect.  The  old  fashioned  term  alter- 
ative was  really  scientific,  so  far  as  it  went,  and  it 
goes,  perhaps,  about  as  far  as,  even  now,  we  are  able 
to  go  in  our  analysis  of  the  modus  operandi  of  very 
inany  of  the  remedies  and  systems  of  treatment  that 
are  to-day  most  esteemed.  The  observed  fact  that 
these  maladies  yield  to  so  many  different  kinds  and 
varieties  of  treatment  is  in  general  explained  by  this 
theory, — anything  that  changes  may  cure.  Medicines 
and  modes  of  treatment  may  change  the  constitution 
by  their  direct,  local  effect,  by  reflex  action,  and  by 
special  affinities  that  certain  drugs  have  for  certain 
jjarts  or  organs,  or  stiiictures,  or  functions.  Many  of 
the  reuKidies  used  in  neurasthenia  may  be  regarded  as 
nerve-alteratii  cs. 

By  this  analysis  we  are  able  to  obtain  at  least  a  gen- 
eral view  of  the  ratioiKde  of  the  tiierapeutics  of  all 
chronic  diseases,  and  of  the  oftentimes  ])uzzling  fact 
that  the  same  rcjmedies  act  so  differently  with  the 
same  person  at  different  times,  and  also  with  different 
constitutions,  and  at  different  periods  of  life. 

J^tcid   Treat un'ut.-\\\  (piite  a  number  of  cases  of 


232  NERVOUS   EXHAUSTION. 

neurasthenia,  no  satisfactory  relief  or  cure  can  be 
obtained  until  we  first  relieve  the  local  disease  from 
whicii  the  general  neurasthenia  originated,  and  by 
which  it  is  maintained.  The  irritations  of  the  diges- 
tive and  the  reproductive  apparatus  are  reflected  to  the 
brain,  the  spine,  the  eyes,  the  ears,  and  by  them  to 
the  whole  system.  The  disease  in  these  parts,  closely 
connected  by  many  large  plexuses  of  nerves  through 
the  whole  system,  reacts  on  the  whole  system  and 
neutralizes,  in  a  degree,  the  remedies  that  we  employ 
in  our  constitutional  treatment.  In  the  diagnosis  of 
neurasthenia,  it  is  needful,  as  has  been  seen,  to  trace 
out  these  local  disorders  of  special  organs,  in  order  to 
learn  the  cause  and  the  complications  of  the  special 
malady;  and  in  our  treatment  it  is  also  necessary, 
whatever  constitutional  reaef  may  be  employed,  to 
remove  these  local  difficulties  A  long  war  has  been 
going  on  between  the  advocates  of  constitutional  and 
local  treatment:  but  there  should  be  no  war  between 
these  methods;  for  the  true  science  and  art  of  medicine 
require  a  unison  between  the  two — the  one  should 
supplement  the  other.  To  depend  upon  one  to  the 
exclusion  of  the  other  is  short-sighted  and  unscientific, 
and  the  source  of  disappointments  and  failures  innu- 
merable. 

Disorders  of  the  stomach  and  liver  may  become  foci 
that  liarht  up  the  whole  system  with  disease,  and 
demand,  both  on  scientific  and  on  practical  grounds, 
a  special  local  treatment  at  the  same  time  with  our 
constitutional  treatment. 

On  this  subject  mistakes  are  made  both  ways — first, 
hv  using  nothing  but  local  treatment;  and,  secondly, 
by  neglecting  it  entirely.  In  very  many  cases,  all  the 
geueral  symi)toms  remain  after  the  local  disease  is 
cured.     The  flames  that  have  spread  over  the  system 


HYGIENE  OF  NERVOUS  EXHAUSTION.  233 

are  not  to  be  extinguished,  though  the  sources  from 
which  they  originated  have  burned  up.  In  males  self- 
abuse,  especially  when  begun  in  early  years,  before  or 
just  after  puberty,  is  one  of  the  most  frequent  of  the 
exciting  causes  of  many  of  the  local  and  also  general 
symptoms  of  nervous  exhaustion.  In  females,  exces- 
sive child-bearing,  the  injuries  that  follow  parturition, 
and  uterine  and  ovarian  congestions  resulting  from 
various  causes,  are  often  the  starting-points  of  every 
conceivable  phase  of  functional  nervous  disorders, 
fi'om  mild  and  transient  neurasthenia  through  all  the 
gradations  to  severe  melancholia. 

To  neglect  local  treatment  in  cases  with  such  a  his- 
tory is  to  neglect  our  patient.  I  see  many  failures  of 
purely  general  treatment  from  this  cause  alone. 

Persistence  in  Treatment  — Perseverance  is  an  ele- 
ment which  is  required  both  on  the  part  of  the  physi- 
cian and  of  the  patient.  Diseases  of  many  years 
standing  are  not  to  be  driven  from  their  strongholds 
by  a  single  prescription,  or  by  a  brief  and  temporary 
respite  from  care.  It  is  not  necessary  to  abandon  one's 
business  or  profession.  One  can  keep  right  on  with  his 
daily  duties  in  very' many  cases;  but  it  is  necessary 
to  mak(i  the  treatment  in  a  measure  a  matter  at  once 
of  conscience  and  of  routine;  as  an  incident  to  our  pro- 
fession or  occupation,  for  weeks,  and  in  some  cases, 
montiis.  It  is  not  necessary  to  be  taking  medicine 
all  this  time,  but  it  is  necessary  to  be,  so  to  speak, 
under  arms— pro[)ared  to  meet  any  symptoms  as  they 
may  arise,  and  take  medicine  off  and  on  as  it  may  be 
convenient. 

Very  rarely  indeed  do  I  advise  a  patient  to  change 
his  i)rofession  or  occupation,  whatever  it  may  be,  pro- 
vided he  is  hai)py  and  successful  in  it.  In  a  large 
number  of  cases  I  urge,  especially  upon  young  men, 


234  NERVOUS    EXHAUSTION. 

the  necessity  of  obtaining  some  occupation;  and  I 
would  rather  have  them  work  too  hard  than  not  work 
at  all. 

In  setting  out  on  the  voyage  across  the  Atlantic,  we 
are  not  on  lookout  for  a  sight  of  Fastnet  Light  the 
first  day,  but  quietly  resign  ourselves  to  the  care  of 
the  officers  of  the  ship,  meanwhile  occupying  and 
amusing  ourselves  as  best  we  can.  Just  so  the  neu- 
rasthenic on  the  voyage  toward  health  is  not  to  be  im- 
patient for  the  end,  nor  expect  to  celebrate  its  comple- 
tion in  twenty-four  hours,  but  should  trust  himself  in 
the  hands  of  his  adviser  who  is  to  think  and  watch  for 
him,  while  he  himself  obeys  his  commands  and  attends 
to  his  own  concerns. 

Treatment  of  Sequences.— The  above  plan  of  treat- 
ment applies  not  only  to  nervous  exhaustion,  both 
spinal  and  cerebral,  but  to  many  of  the  sequences  of 
neurasthenia  as  described  in  Chapter  IV.— melan- 
cholia, hysteria,  hystero-epilepsy,  inebriety,  opiomania, 
and  certain  phases  of  professional  cramp  as  well  as 
albuminuria  can  be  treated  successfully  in  this  way. 
Always,  in  all  that  we  do  for  neurasthenia,  it  should 
be  remembered  that  it  is  not  the  remedy  that  cures, 
but  the  physician  who  cures,  making  use  of  the 
remedy.  It  is  the  way  in  which  these  methods  of 
treatment  are  used  that  determines  the  result.  All 
these  processes  can  be  so  used  as  to  do  harm,  and  aU 
of  them  can  be  so  used  by  a  wise  physician  as  to  re  • 
lieve  and  cure. 

General  and  Special  Effects  of  this  Comhined  Treat- 
ment.— The  powerful  sedative  and  tonic  effects  of  gen- 
eral faradization  and  central  galvanization  used  by 
themselves  have  several  times  been  explahied  in  detail 
in  my  writings,  and  the  claims  therein  made  have 
been  confirmed  by  many  other  observers,  as  Vater, 


HYGIENE   OF   NERVOUS   EXHAUSTION.  235 

Benedict,  and  Erb  in  Germany,  and  Mitchell  and  many 
others  in  this  country. 

Under  this  combined  treatment,  medication,  hygiene, 
massage,  and  electricity,  these  sedative  and  tonic 
effects  are  hastened,  extended,  and  made  more  per- 
manent; and  cases  that  under  any  single  and  exclu- 
sive method  would  find  but  partial  relief  are  entirely 
cured. 

Improvement  in  Sleej). — As  one  of  the  most  constant 
symptoms  of  neurasthenia  is  wakefulness,  so  one  of 
the  first  signs  of  improvement — the  earliest  evidence 
that  the  treatment  is  doing  the  work  designed — is 
sounder  sleep  and  more  of  it;  there  is  less  of  troubled 
dreaming,  of  nightmare,  of  restlessness,  of  tossing  and 
pitching  about,  of  positive  unrest.  The  patient  finds 
that  he  can  give  up  his  chloral  and  falls  to  sleep  more 
readily  and  spends  more  hours  in  unconsciousness 
than  before.  This  improvement  in  sleep  appears 
sometimes  during  the  first  week  of  treatment,  and 
even  on  the  very  first  few  nights. 

The  function  of  sleep  is  perhaps  the  best  of  all 
barometers  of  functional  nervous  disease;  since  nearly 
all  cases  of  neurasthenia  and  allied  disorders  are  ac- 
companied by  drowsiness  or  wakefulness,  and  the 
correcting  of  these  conditions  is  a  proof  that  the 
patient  is  on  the  mend.  In  organic  nervous  troubles, 
on  the  other  hand,  the  sleep  is  often  if  not  usually 
normal;  in  ataxy,  in  the  various  forms  of  chronic 
myelitis,  in  paralysis  from  grave  cerebral  disease,  the 
patient  may  sleep  as  well  as  in  perfect  health.  In 
some  cases,  the  incipience  of  nervous  disorder  is 
marked  by  insomnia,  while  in  the  later  and  severer 
stages  this  symj»t(>m  pass(!s  away.  Sleep  is  its«?lf  food 
and  medicine,  and  when  it  is  restored,  all  tho  other 
functions  share  in  the  restoration.     When  a  patient 


236  NERVOUS  EXHAUSTION. 

is  made  to  sleep  without  forcing  measures  we  may 
know  by  that  fact  alone  that  he  is  improving. 

[For  the  insomnia  which  is  so  frequently  associated 
with  neurasthenia  I  know  of  no  remedy,  taking  the 
cases  as  we  find  them,  that  offers  so  much  in  the  way 
of  relief  as  electricity.     General  faradization  is  often 
of  the  utmost  service,  but  in  many  cases  where  this 
and  all  other  methods  have  failed  to  produce  the  de- 
sired result,   the  galvanic    current  properly  applied 
proves  rapidly  efficacious.     The  remedy  has  in  my 
hands  acted  so  well,  that  I  may  be  allowed  in  a  few 
words  to  emphasize  the  matter.     If  a  patient  can  be 
made  to  sleep  without  forcing  measures,  as  has  just 
been  observed,  so  much  the  better,  but  too  frequently 
the    administration    of    some  sleeping  potion  is  for 
a  time  unavoidable.     For  the  production  of  sleep,  how- 
ever, electricity  is  not  a  forcing  measure  in  the  sense 
that  we  use  the  term  as  applied  to  chloral,  opium,  and 
other  internal  remedies  of  their  kind.     If  it  produces 
sleep  on  one  night  and  its  application  is  omitted  the 
next,  the  patient  is  none  the  worse  because  of  its  ad- 
ministration, but  is  on  the  contrary  more  inclined  to 
restfulness  on  the  second  night,  because  of  the  previous 
treatment.     The  effects  of  electricity  on  the  sleep  of  a 
neurasthenic  patient,  whether  used  in  the  form  of  gen- 
eral faradization,  general  franklinization,  or  galvani- 
zation of  the  central  nervous  system,  are  both  tem- 
porary and  permanent.     The  temporary  relief  that 
appears  the  night  or  two  following  an  application, 
though  usually  less  potent  than  those  of  bromide  of 
potassium    and    hydrate    of    chloral,    are    yet    very 
decided;  but  it  is  for  the  permanent  relief  that  electri- 
zation is  chiefly  indicated  in    this  symptom.     This 
comes  gradually,  slowly,  and  as  a  result  of  the  im- 
provement of  the  morbid  condition  on  which  the  in- 
somnia depends. 


HYGIENE   OF  NERVOUS   EXHAUSTION.  237 

In  the  treatment  by  the  galvanic  current,  much 
depends  upon  the  sufficiency  of  the  treatment  as 
regards  strength  of  current  and  the  care  with  which 
it  is  administered.  An  illustrative  case  is  sometimes 
more  impressive  than  a  mere  statement  of  fact,  and 
the  following  case  is  therefore  related  not  only  as  an 
example  of  the  good  effects  of  treatment  but  as  de- 
scriptive of  a  method  which  has  on  the  whole  proven 
more  efficacious  for  the  permanent  relief  of  insomnia 
than  any  other.  A  gentleman  in  the  prime  of  life  had 
for  several  years  been  a  sufferer  from  many  of  the 
varied  symptoms  of  neurasthenia,  and  finally  from 
this  cause  alone  resigned  his  partnership  in  an  exten- 
sive and  most  profitable  mercantile  business.  He 
travelled  extensively  and  was  treated  in  many  cities, 
but  without  finding  the  relief  that  he  sought  for. 
Finally,  insomnia  of  a  most  persistent  type  supervened, 
and  for  six  months  lie  never  slept  without  the  aid  of 
either  bromide  or  chloral,  and  even  with  these  he  had 
lately  suffered  many  wakeful  hours  when  he  should 
have  slept.  He  finally  resolved  of  his  own  volition  to 
abandon  all  soporifics.  For  ten  days  he  faithfully 
kept  tliis  resolve,  but  no  sleep  came  to  him,  and  he 
was  forced  to  resort  once  more  to  chloral.  Shortly 
after  he  fell  under  my  observation  and  was  treated 
with  the  galvanic  cun'ent  acciu-atoly  measured. 

Placing  a  large  metal  electrode  (covered  with  a 
smooth  layer  of  absorl)ent  cotton  with  a  second  cover- 
ing of  chamois  skin)  over  the  solar  plexus,  and  a 
second  large  electrode  of  fine  sponge  over  the  cilio 
spinal  centre,  an  ascending  cuirent  was  ai)phed. 

Beginning  with  a  few  cells  the  number  was  grad- 
ually increased  without  intern.ii)tion  until  a  current 
strength  of  sixty  niiiliamperes  was  reached  and  con- 
tinued for  eight  or  ten  minutes. 


238  NERVOUS  EXHAUSTION. 

The  current  was  then  as  gradually  decreased  to  zero. 
That  night,  without  the  administration  of  a.ny  internal 
remedy,  the  patient  slept  six  hours,  and  the  second 
night,  after  a  second  similar  application,  he  slept 
soundly  for  seven  hom'S.  To  detail  further  the  history 
of  this  case  would  be  simply  a  repetition.  He  was 
under  observation  for  one  month,  receiving  the  same 
treatment  nearly  every  day.  At  the  end  of  that  time 
he  found  it  necessary  to  go  abroad  on  matters  of  im- 
portance, but  the  improvement  in  sleep  that  had  been 
gained  remained  permanent,  I  gave  him  letters  of 
introduction  to  prominent  parties  in  England,  France 
and  Germany,  fully  describing  the  case  and  my 
method  of  treatment,  but  he  found  it  unnecessary  to 
make  use  of  them.] 

Mental  and  Physical  Sedation. — There  is  more  of 
calmness,  of  repose,  of  serenity  of  feeling  and  manner; 
the  patient  finds  it  less  difficult  to  sit  or  keep  still 
without  working  or  moving  the  limbs.  He  is  less 
fretful  and  irritable.  The  abnormal  tension  and  activ- 
ity frequently  observed  in  functional  nervous  maladies 
disappear,  and  while  the  capacity  for  work  increases 
the  ability  to  abstain  from  working  without  fretting 
or  chafing  also  increases. 

Increase  in  Fat  and  Weight  of  the  Body. — Again 
and  again  have  I  seen  the  dyspeptic  and  the  emaciated 
fill  out  under  this  regimen,  even  when  they  pursued 
their  regular  callings. 

This  gain  of  fat  in  a  few  weeks  reaches  its  limit,  be- 
yond which  it  cannot  be  forced  by  any  continuance  or 
combination  of  the  treatment,  and  it  is  not  observed  to 
the  same  degree  in  all  cases,  even  of  those  that  are 
perfectly  cured. 

On  returaing  to  active,  normal  life,  some  of  this 
added  flesh  remains  as  a  permanent  possession,  while 
some  may  gradually  disappear. 


HYGIENE   OF   NERVOUS   EXHAUSTION.  239 

Improvement  in  Ajjjjetite  and  Digestion. — Caprice  of 
appetite  and  digestion  almost  always  accompanies  the 
varied  forms  of  neurasthenia,  and  any  treatment  that 
relieves  these  synjptoms  is  doubly  gi-ateful,  in  the 
direct  comfort  that  it  gives,  and  in  the  indirect  effect 
on  the  nutrition  of  the  body. 

Even  those  that  are  confined  to  bed  and  allowed  no 
active  exercise  find  their  digestion  daily  growing 
stronger;  their  capacity  for  taking  and  for  assimilating 
large  quantities  of  food  astonishes  themselves  and 
their  friends.  After  a  time  this  improvement  in  ap- 
petite, like  the  increase  in  body  weight,  reaches  its 
limit;  less  food  is  demanded,  as  though  the  system, 
long  exhausted  and  badly  nourished,  had  become,  so 
to  speak,  saturated,  or  had  been  brought  up  to  its  nor- 
mal state. 

Relief  of  Special  Symptoms  of  Weariness,  Exhaus- 
tion,  and  Pain. — Neuralgia,  headache,  backache,  cardi- 
algia,  pain  in  the  eyes  after  using  or  on  exposure  to 
bright  liglit,  tinnitus,  palpitation,  vague,  wandering  dis- 
tress in  all  parts  of  the  frame,  general  or  local  tender- 
ness, attacks  of  numbness  and  stiffness,  spasms.twitch- 
ings.  sensations  of  rolling,  of  beating,  of  burning,  of 
l)ricking,  of  crawling,  liashos  of  h«\at  and  cold,  attacks 
(jf  overwhelming  exhaustion  and  depression,  chilliness 
of  the  extremities- -all  tliese  results  of  the  neurastheni(' 
state  arc  modified  more  or  less  quickly  after  the  above 
course  of  treatment  is  in  full  operation.  In  some 
instances  relief  of  tliese  various  morbid  sensations 
does  not  reach  any  degree  of  permanency  until  the 
patient  has  been  for  some  time  under  care,  although 
tenqxjrary  relief  or  alleviation  very  often  appears  the 
first  week  of  treatment. 

Increased  Capacity  for  Mnscidar  and  Cerebral  Toil. 
— Patients  who  at  the  outset  of  this  treatment  are  un- 


240  NERVOUS    EXHAUSTION. 

able  to  walk  a  block  or  even  across  the  room,  who 
cannot  concentrate  the  mind  sufficiently  to  write  a 
letter  or  read  a  newspaper,  experience  a  gradual 
though  not  always  a  steady  renewal  of  their  powers; 
they  find,  after  a  period  varying  from  several  days  to 
several  weeks,  that  they  can  begin  to  return  to  their 
usual  duties.  The  flabby  and  relaxed  muscles  acquire 
firmness,  hardness  and  solidity;  there  is  less  of  the 
wet-rag  feeling  so  common  in  these  cases. 

Those  who  have  been  utterly  disheartened,  and  have 
resigned  the  expectation  of  ever  again  taking  part  in 
active  work  of  any  kind,  are  more  than  restored,  and 
are  able,  in  some  cases,  to  labor  harder  than  before; 
the  system  seems  to  have  been  rested  both  by  the  dis- 
ease and  its  treatment,  just  as  after  an  attack  of 
typhoid  fever. 

As  work  is  itself,  when  well  ordered,  one  of  the 
means  of  cure  of  some  forms  of  nervous  exhaustion, 
the  return  of  the  power  to  work  is  itself  a  medicine 
which,  in  time,  makes  it  possible  to  displace  all  other 
treatment 

Travelling  as  Medicine. — The  fashionable  method  of 
treating  all  forms  of  functional  nervous  disease,  is  by 
recommending  a  trip  to  Europe.  Ev^en  where  no 
diagnosis  is  made,  or  where  the  vague  expression 
"  general  debility  "  only  is  used  to  indicate  the  morbid 
condition,  this  prescription,  "a  trip  to  Europe,"  is 
hastily  ordered. 

For  years  it  has  been  the  custom,  when  the  patients 
complained  of  any  or  of  all  of  these  symptoms  that  I 
have  described  under  neurasthenia,  to  fall  back  on  the 
recommendation  of  travel  as  a  panacea,  adapted  aUke 
to  all  stages  and  sexes.  If  we  do  not  know  what  is 
the  matter  with  the  patient,  we  assume  that  his  symp- 
toms are  imaginary,  or  if  not  imaginary,  trifling,  and 


HYGIEXE   OF   NERVOUS   EXHAUSTION.  241 

that  they  require  no  medicine,  no  special  medical 
treatment,  no  careful  medical  observation,  no  well- 
directed  hygiene  even.  A  long  vacation,  a  protracted 
absence,  is  supposed  to  be  a  specific  for  all  such  condi- 
tions. In  some  cases,  this  prescription  does  work 
most  excellently;  in  other  cases,  its  results  are  nega- 
tive, and  in  other  cases  evil,  and  only  evil  results  are 
obtained. 

I  have  constantly  under  my  care  cases  of  both  forms 
of  neurasthenia,  who  liave  spent  months  and  years 
abroad,  under  advice  of  physicians,  not  only  without 
benefit,  but  in  some  instances  have  been  positively  in- 
jured. Cases  of  myelasthenia  (spinal  exhaustion)  es- 
pecially are  very  liable  to  be  made  worse  by  the  fatigue 
of  travel,  by  the  discomfort  of  absence  from  home,  by 
the  laborious,  and  oftentimes  wearisome  and  exhaust- 
ing tasks  of  sight-seeing.  Many  are  worn  out  in  the 
picture  galleries,  and  in  mountain  climbing,  and  must 
return  home  to  rest  and  recover  from  the  effects.  Not 
unfrequently  cases  of  this  class  progress  more  satisfac- 
torily at  home,  when  their  minds  are  occui)i(^d  with 
their  favorite  employment,  even  though  sometimes 
they  may  bo  overtasked  in  it,  and  become  at  tilings 
over  wearied  and  excited.  In  the  case  of  a  proininent 
man  that  I  now  recall — cerebrasthenia  comphcated 
with  myelasthenia — ^^who  spent  a  whole  year  abroad, 
and  who  consulted  me  on  his  return,  it  was  found  on 
resuming  the  topics  in  which  he  was  especially  inter- 
ested, that  he  was  much  better  than  when  idling  his 
time  in  foreign  lands. 

Travelling,  indeed,  is  no  more  a  specific  than  any 
other  medicine  is  a  specific.  Indiscriminately  pre- 
scrilxjd,  especially  without  making  a  difYerential  diag- 
nosis of  the  case,  it  is  unscientific.  It  is  oiui  of  the 
best  remedies;  it  may  be  one  of  the  worst  remedies;  it 


242  NERVOUS  EXHAUSTION. 

may  be  a  specific  for  a  certain  case;  it  may  be  precisely 
the  most  injurious  thing  that  can  be  suggested  for 
another  case,  Ahiiost  all  medicines  are  apt  to  be  used 
indiscriminately,  but  I  doubt  whether  there  is  any 
medicine  which  is  more  indiscriminately  used  than 
travel,  especially  in  the  form  of  a  trip  to  Europe. 

For  the  majority  of  cases,  judicious  treatment  does 
more  good  than  travel.  Very  often  I  am  called  upon 
to  treat  those  Avho  have  travelled  almost  everywhere, 
seeking  help  and  finding  none.  One  month,  or  even 
one  week  of  treatment  will  oftentimes  do  more  for  the 
relief  of  the  worst  neurasthenic  symptoms,  than  a 
whole  year  of  travel.  One  needs  indeed  a  certain 
degree  of  health  and  nerve-force  to  travel  with  pleasure 
or  advantage:  as  a  supplement  to  treatment,  sensible 
travel  is  often  of  the  highest  benefit. 

Short  Vacations. — In  the  cases  that  are  supposed  to 
be  nervous  prostration,  the  very  best  results  are  often- 
times accomplibUed,  in  both  cerebrasthenia  and  myelas- 
thenia.  when  the  patient  remains  at  home,  or  near  at 
home,  or  at  least  in  his  own  country,  by  short  vaca- 
tions. Trills  that  last  for  perhaps  but  two  or  three 
days,  or  even  a  single  day,  especially  a  change  from 
city  to  country  air,  sometimes  brings  great  relief. 
And  oftentimes  there  is  no  need  of  breaking  up  busi- 
ness, or  interfering  with  the  plans  of  life. 

Horse-hack  Riclimj. — Horse-back  riding,  like  travel 
in  Europe,  is  a  remedy  that  has  been  most  unscien- 
tifically recommended  and  used.  Like  travel,  it  may 
be  one  of  the  best  or  one  of  the  worst  of  exercises, 
according  to  the  temperament  and  special  condition  of 
the  patient.  In  individual  cases  it  is  a  specific  for 
good;  in  other  cases  it  is  a  specific  for  harm.  I  have 
seen  patients  whose  maladies  were  brought  on  or 
jnade  much  worse  by  severe  riding,  kept  up  for  a  long 


HYGIENE  OF  NERVOUS  EXHAUSTION.  243 

time;  and  I  have  seen  cases  where  this  mode  of  exer- 
cise seemed  to  do  more  than  almost  anything  else  in 
bringing  about  a  cure. 

Where  there  is  any  trouble  with  the  prostatic 
urethra,  riding  horse-back  is  likely  to  do  injury — to 
interfere  with  treatment,  if  not  to  neutrahze  it  en- 
tirely. A  number  of  physicians  who  have  consulted 
me,  have  been  clearly  uijm'ed  by  their  long  rides  in 
their  country  practice.  Even  where  there  is  no  local 
difficulty,  the  exercise  of  riding  is  far  too  severe  for 
many  nervous  constitutions.  Two  members  of  a  pub- 
hshing  firm  of  this  city,  who  were  under  my  care  some 
years  since,  were  both  obliged  to  abandon  this  form  of 
exercise,  and  substitute  riding  in  an  open  carriage. 

A  medical  friend,  who  served  during  the  war  in  the 
cavalry,  had  the  curiosity  to  take  an  hour's  ride  in  one 
of  the  riding  schools  of  this  city,  and  was  made  sick 
for  a  week  as  the  result. 

Riding  liorse-back,  like  cold  bathing,  is  a  delightful 
luxury  for  the  well,  but  a  powerful  medicine  for  the 
sick,  and,  like  other  powerful  medicines,  must  be  pre- 
scribed and  used  with  study  and  discrimination.  This 
same  suggestion  applies  to  sea  bathing,  and  to  Russian 
and  Turkish  baths,  gymnastics,  and  lifting  cures. 

I  emphasize  this  dark  side  of  a  most  valuable  form 
of  open-air  exercise,  because  it  is  currently  believed 
that  it  is  a  specific  for  all  shapes  of  nei-vousness. 

Clothing. — The  neurasthenic  oftentimes  need  to 
dress  warm(3r  than  tliose  in  health.  Sometimes  they 
must  be  more  careful  in  this  respect  than  consump- 
tives; not  only  thick  underclothing,  but  two  sets  very 
often  barely  suffice  to  keep  them  comfortable  in  mid- 
winter. There  are  some  who  cannot  get  warm,  no 
matter  how  they  dress.  The  neurasthenic  c'annot  be 
comfortable,  unless  in  a  room  where  the  thermometer 


244  NERVOUS  EXHAUSTION. 

registers  below  70°,  and  some  require  even  greater 
heat.  Dr.  Richardson,  of  London,  would  have  the 
temperature  of  the  rooms  of  Salut  Laud  uniformly  at 
60°;  in  such  a  city  the  neurasthenic  and  nervous 
Americans  in  general  could  never  be  happy. 

The  Climafolofjy  of  Nervous  Diseases. — The  climat- 
ology of  consumption  has  been  studied  with  more  or 
less  satisfaction  for  years.  It  is  a  subject  that  has  oc- 
cupied the  thoughts  of  a  large  number  of  observ^ers. 
The  chmatology  of  the  diseases  of  the  nervous  system 
has,  however,  received  very  little  attention,  and  has, 
so  far  as  I  know,  a  very  meagre  literature.  There  are 
three  general  varieties  or  classes  of  nervous  diseases. 

First,  purely  functional  diseases — neuroses  as  they 
are  called;  under  this  head  come  neurasthenia  and 
allied  disorders. 

Secondly,  structural  or  organic  nervous  diseases, 
such  as  paralysis  of  a  central  origin,  ataxia,  j)rogressive 
muscular  atrophy,  spinal  paralysis  of  adults  and  infants, 
and  certain  forms  of  sciatica  and  tic  douloureux. 

Thirdly,  nervous  diseases  that  are  between  the  func- 
tional on  the  one  hand  and  the  organic  on  the  other. 
Under  this  head  come  certain  forms  of  epilepsy  and  of 
chorea,  possible  also  tetanus  and  paralysis  dependent 
on  rupture  of  the  blood-vessels  of  the  brain,  which  are 
called  nervous  diseases,  although  in  strictness  they  are 
hardly  nervous,  but  vascular  diseases,  the  nerve  dif- 
ficulty that  results  from  them  being  of  a  mechanical 
character.  Under  this  head  are  also  to  be  included 
some  of  the  different  forms  of  professional  cramp,  as 
writers,  telegraphers,  musicians,  painters,  barbers,  etc' 

'  On  this  subject  I  may  refer  to  my  paper,  entitled  "  Analysis 
of  One  Hundred  and  Twenty-five  Cases  of  Writers'  Cramp  and 
allied  Affections,"  published  in  the  Medical  Record,  March  15th, 
1879. 


HYGIENE  OF  NERVOUS  EXHAUSTION.  245 

Very  much  of  false  reasoning  on  the  subject — on  the 
history  and  statistics  of  nervous  diseases — is  the  re- 
sult of  misconception  on  this  point.  Insanity  may 
come  mider  any  one  of  the  three  orders. 

The  first  proposition  in  regard  to  cUmatology  of  dis- 
eases is  this,  that  all  forms  of  nervous  diseases,  both 
structural  and  functional  and  also  those  that  partake 
of  the  quaUties  of  both,  are  more  common  in  the  tem- 
perate regions  than  in  the  extremes  of  heat  and  cold. 
In  the  extreme  North,  in  the  polar  regions,  or  in  the 
extreme  South,  in  the  tropics,  nervous  diseases  are 
very  rare,  and  the  increase  in  our  nervous  diseases  is 
demonstrable  as  we  go  from  the  poles  towards  the 
temperate  zone,  or  from  the  tropics  northward.  In 
this  belt,  which  includes,  in  the  Eastern  continent,  a 
large  portion  of  Germany,  Great  Britain,  and  a  north- 
em  portion  of  France,  and  in  this  continent  the  north 
portion  of  the  United  States,  nervous  diseases  are 
found  more  than  in  any  other  part  of  the  world  out- 
side of  this  belt.  Northward  or  southward  there  are 
found  cases  of  palsy  of  cerebral  origin,  such  as  I  have 
referred  to;  and  deaths  from  that  cause  are  frequent, 
even  among  the  partially  civilized.  Nei-vous  diseases 
that  are  really  of  a  nervous  character,  the  direct  re- 
sults of  a  disorder  of  the  nervous  substance,  are  com- 
paratively rare,  or  of  far  less  frequency  in  Italy,  Spain, 
or  in  the  northern  portions  of  Euroj^e,  in  Canada,  in 
the  Gulf  States  of  America,  and  in  South  Amercia, 
than  in  this  belt  that  I  have  just  described. 

The  prime  cause  of  nervous  disease  is,  without  any 
doubt,  nervous  dev(;lopinent  and  activity;  which  ac- 
tivity in  our  higher  forms  of  civilization,  especially  in 
modern  times,  is  carried  to  a  degree  from  which  nei'v- 
ous  diseases  must  be  the  inevitable  results. 

Secondly.  Patients  affected  with  uem-asthenia  and 


^46  NERVOUS  EXHAUSTIOl?. 

allied  functional  nervous  diseases  are  usually  benefited, 
or  liable  to  be  benefited,  by  visiting  the  warm  regions 
in  this  country.  In  the  United  States,  neurasthenia 
diminishes  in  frequency  as  we  go  south. 

Neurasthenic  sufferers  who  spend  a  portion  of  the 
cold  weather  in  Florida  and  the  Gulf  States  receive  as 
much  benefit,  if  not  more,  than  consumptives  who 
visit  the  same  localities. 

In  Europe,  cases  of  similar  character  are  sent  to  the 
south  of  France  and  Italy  and  Algeria. 

Those  who  spend  a  portion  of  the  colder  season  in 
those  benign  climates  are  profited  in  various  ways; 
they  escape  the  congestions  of  the  spinal  cord  that  are 
often  brought  on  and  kept  up  by  the  cold  weather  of 
our  northern  climates;  they  escape  also  the  confine- 
ment in  close  and  excessively  heated  rooms,  which  is 
absolutely  necessary  for  a  number  of  months  in  our 
climate. 

The  equitable  temperature  of  regions  like  the  Baha- 
mas, Florida,  and  Nice,  makes  it  possible  to  spend  a 
large  portion  of  the  time  in  the  open  air.  This  change 
nervous  patients  appreciate  in  common  with  consump- 
tives. Cases  of  cerebral  congestion  and  exhaustion, 
of  neurasthenia  in  its  different  forms,  of  hay  fever,  are 
sometimes  permanently  cm-ed,  and  almost  always  re- 
lieved, more  or  less,  by  a  long  residence  in  a  warm 
chmate. 

M}'^  friend.  Dr.  W.  F.  Hutchinson,  of  Providence, 
Ehode  Island,  in  an  interesting  paper,  lately  published 
in  the  Medical  Record,  on  "  CUmate  Cure  for  Nervous 
Diseases,"  highly  recommends  the  Sandwich  Islands 
as  a  resort  for  the  nervous,  on  account  of  its  equable 
and  agreeable  temperature.  My  friend  and  class- 
mate. Justice  Judd,  of  the  Supreme  Court  of  the  Sand- 
wich Islands,  tells  me  that  on  a  visit  in  the  States  he 


HYGIENE  OF  Nervous  exhaustion.  247 

is  surprised  to  hear  people  so  constantly  talking  about 
the  weather;  he  says  that  in  the  Islands  it  is  expected 
that  the  weather  will  be  pleasant.  Recently  he  has 
heard  they  have  had  a  cold  snap  in  the  neighborhood 
of  35  or  45  degrees,  which  has  caused  great  astonish- 
ment there.  There  is  httle  doubt  that  the  Sandwich 
Islands  would  be  almost  an  ideal  sanitarium  for  the 
nerve-exhausted.  Next  to  these  come,  as  Dr.  Hutch- 
inson recommends,  some  of  the  West  India  islands. 

Thirdly.  The  air  of  mountainous  regions  is  of  special 
benefit  to  nervous  patients.  In  elevated  regions,  the 
atmosphere  is  rarer  and  more  free  from  irritants  than 
at  the  sea  level.  A  factor  of  importance,  also,  is  that 
the  temperatures  are  colder  as  we  go  up;  the  atmos- 
phere contains  more  of  atmospheric  electricity,  and  of 
ozone;  but  one-half  of  the  advantages  of  a  residence  in 
mountainous  regions  is  due  to  the  fact  that  large  forests 
extend  in  every  direction  from  the  mountains;  the  air 
of  the  forests,  as  the  air  of  the  ocean,  is  pure;  all  these 
complex  factors  contribute  to  the  favorable  results 
that  sometimes  follow  even  short  visits  to  a  mountain- 
ous region,  whether  that  of  the  "\\Tiite  Mountains,  the 
Adirondacks,  or  tlie  mountains  of  Switzerland.  In 
very  many  instances,  according  to  my  observation, 
patients  are  more  benefited  by  spending  summer 
among  the  mountains  than  at  the  sea-side. 

A.t  the  sea -side  we  do  not  always  get  the  sea  air,  for 
when  the  wind  blows  from  the  land,  not  only  is  the 
temperature  hot,  but  the  air  is  laden  with  the  imi)uri- 
ties  which  abound  in  all  cultivated  regions.  Observa- 
tions have  made  clear  that  in  all  cultivated  districts, 
the  air  for  hundreds  of  feet  in  altitude  is  filled  with 
vegetable  irritants.  From  these  impurities  and  dis- 
turbing influences,  the  sea  and  higli  mountain  air  is 
comparatively   free.     If    dwellers    by   the   sea  could 


248  NERVOUS  EXHAUSTION. 

always  get  the  sea  air  in  strong  doses  without  the  land 
breezes,  they  Avoald,  no  doubt,  be  benefited  far  more 
than  is  ordinarily  the  case — perhaps  fully  as  much  as  by 
an  ocean  voyage.  It  is  partly  because  of  this  uncertainty 
of  the  wind  that  hay-fever  sufferers  are  benefited  in  a 
much  larger  proportion  by  a  residence  in  the  White 
Mountain  region  than  at  any  of  our  sea-side  resorts.  I 
am  persuaded  that  nervous  patients  are,  in  very  many 
instances,  if  not  in  the  majority  of  instances,  more 
benefited  by  visits  to  the  White  or  Adirondack  Moun- 
tains, or  Switzerland,  than  by  a  visit  to  the  sea-side. 

To  this  rule  there  are  occasional  exceptions.  I  have 
seen  persons  who  cannot  remain  long  in  Bethlehem, 
White  Mountains,  which  is  perhaps  1,500  or  2,000  feet 
above  the  level  of  the  sea.,  without  experiencing  head- 
ache. I  know  a  man  who  regularly  visits  that  place, 
but  who  also  comes  away  in  about  a  week,  for  the  rea- 
son that  all  the  benefit  he  can  derive  is  over  by  that 
time.  On  the  other  hand,  I  know  a  case  of  general 
neuralgia  that  is  always  relieved  at  once  on  visiting 
the  same  region,  and  the  relief  abides  not  only  while 
there,  but  for  a  number  of  months  on  returning 
home;  and  in  general  it  may  be  stated  that  functional 
nervous  diseases  of  all  kinds  are,  as  a  rule,  benefited 
temporarily  and  permanently  by  a  visit  to  that  region. 
Organic  nervous  troubles  are,  however,  but  shghtly 
benefited  in  comparison.  One  of  the  best  barometers 
for  change  of  climate  is  improvement  in  sleep.  When 
one  sleeps  well,  it  is  safe  to  assume  that  he  has  re- 
ceived benefit  from  the  change  of  chmate.  This  is  one 
of  the  conspicuous  benefits  that  come  from  a  sea  voy- 
age, for  those  at  least  who  are  not  annoyed  by  sea 
sickness^  or  who  have  no  idiosyncrasy  against  salt  air. 

'  Sea  sickness  can  now  in  a  considerable  degree  be  prevented 
or  controlled.  See  a  monograph  by  Geo.  M.  Beard.  Published 
by  E.  B.  Treat,  New  York. 


HYGIENE  OF  NERVOUS  EXHAUSTION,  249 

Fourthly.  Mountainous  regions  above  certain  alti- 
tudes, say  about  twenty-five  hundred  or  three  thou- 
sand feet,  and  between  that  and  six  or  seven  thousand, 
seem  to  have  an  injurious  effect  on  the  nervous  sys- 
tem. In  Colorado,  for  example,  between  five  and  six 
thousand  feet  above  the  level  of  the  sea,  there  is  not, 
according  to  the  investigations  of  my  friend,  Dr. 
Denison  of  Denver,  as  much  improvement  in  nervous 
symptoms  in  those  who  remove  to  that  climate  as  in 
those  who  remove  to  somewhat  lower  altitudes;  the 
capacity  for  continued  muscular  efforts  is  not  so  great 
as  it  would  be  in  a  denser  atmosphere. 

The  petlestrian  feats,  of  which  we  now  hear  so 
much,  could  not  be  accomphshed  in  these  high  alti- 
tudes; and  even  mental  exertion  of  a  higher  order 
would,  to  the  majority  of  persons,  be  more  fatiguing. 
In  these  very  high  altitudes,  there  is  liability  to  neu- 
ralgias, headaches,  and  general  nervousness. 

In  the  Colorado  re^jion,  these  effects  are  brought 
about,  not  only  by  altitude,  but  through  tlie  dryness 
of  the  atmosphere.  Asthma  in  these  regions  is  almost 
always  relieved,  but  this  is  probably  due,  in  part  at 
least,  as  Dr.  Denison  observes,  to  the  mechanical 
effect—"  the  lessened  atmospheric  pressure  on  the 
respiratory  apparatus." 

Functional  nervous  diseases  are,  on  the  whole,  more 
common  in  the  Northern  and  Eastern  i)arts  of  the 
United  States  than  in  Europe,  while  in  England,  Ger- 
many, and  France,  sti-uctural  nervous  diseases  are  more 
connnun  than  in  this  country. 

We  find  more  of  ataxy  and  muscular  atrophy  in 
Great  Britain  and  Central  Europt*  than  in  any  part  of 
America;  we  find  more  neurasthenia,  liay  fever,  in- 
ebriety, general  neuralgia,  and  nervous  dyspepsia  in 
the  northern  j)art  of  the  United  States  than  in  any 
pai't  of  Euroi^e. 


INDEX. 


Abnormalities    of    the     secre- 
tions, 76. 
Acids,  201. 
Agorjvphobia,  54. 
Albuiiiinuria,  174. 
Alcohol,  201. 
Ansemia,  cerebral,  131. 

distinguished     from 
neurasthenia,  134. 

spinal,  131. 
Anthropophobia,  58. 
Arsenic,  193. 
Asthenopia,  chloral,  200 

neurasthenic,  42 
Astraphobia,  53. 
Atonic  voice,  45. 

Back,  imin  in,  81. 
Blisters,  222. 
Blushing,  67. 
Brain  exhaustion,  147. 

work  in  nervous  diseases, 
187. 
Bright's  disease,  174. 
Bromides,  197, 

Caffeine,  193. 

effects  of,  193. 
Caffcinism,  193. 
Cannabis  indica.  192. 
Cases,  how  to  study,  85. 
Catalepsy,  172. 
Cathartics,  219. 
Cautery,  225 


Cerebral  anaemia,  131. 

hyperaemia,  131. 
Cerebrasthenia,  147. 

active  exercise 
in,  149. 
Chills,  nervous,  99. 
Chloral,  199. 

asthenopia,  200. 
Claustrophobia,  58. 
Climatology    of    nervous     dis- 
eases, 244. 
Clothing,  243. 
Coca,  196. 
Coccyodynia,  80. 
Cod-liver  oil,  201. 
Cold,  applications  of,  219. 
common,  147. 
hands  and  feet,  99. 
Colorado,  climate  of,  249. 
Conjunctiva,  congestion  of,  41. 
Convulsive  movements,  88. 
Cramps,  89. 
Cramp,  writer's,  171. 

Deficient  mental  control,  46. 

Depression,  mental,  49. 

Desire  for  stimulants  and  nar- 
cotics, 75. 

Diagnosis  and  nature  of  neu- 
rasthenia, 118. 

Diathesis,  nervous,  128. 

Digestion,  improvement  in,  289. 

Dilated  pupils,  40. 

Disease,  fear  of,  181. 


262 


INDEX. 


Disturbances  of  the  nerves  of 
special  senses,  42. 

Dryness  of  the  skin,  50. 

Drowsiness,  71. 

Duboisia,  197. 

Dyspepsia,  nervous,  72. 

Dysphagia  (difficulty  of  swal- 
lowing), 88. 

Ears,  noises  in,  44. 
Emissions,  involuntary,  100. 
Exhaustion,  of  brain,  147. 
relief  of,  239. 
spinal,  147. 
unaccompanied  by 
positive  pain,  95. 
Eyes,  change  in  expression  of, 
41. 

Fat,  increase  of,  238. 
Fear  of  close  places,  58. 

contamination,  62. 

disease,  60. 

fears,  61. 

lightning,  53. 

open  places,  54. 

railways,  55. 
Feet,  pain  in,  83. 
Fever,  hay,  170. 
Flushing  and  fidgetiness,  67. 
Functional  disease,  157. 

Galvanic  current,  treatment  of 
central  nervous  system  by, 
207. 

Gaping,  103. 

Gums,  tenderness  of,  72. 

Hands,  sweating,  77. 

Hay  fever,  170. 

Heart,  irritable,  84. 

Headache,  40. 

Heat,  appUcations  of,  219. 

Hereditary  neurasthenia,  162, 


Hemi-neurasthenia,  106. 
Heterophemy,  47. 
Hopelessness,  48. 
Horse-back  riding,  242, 
Hydro-therapeutics,  218. 
Hygiene,  digestive,  178. 

of    nervous    exhaus- 
tion, 176. 
Hyperaemia,  cerebral,  131. 
Hyperajsthesia,  general,  79. 

peripheral,  63. 
Hypochondriasis       (pathopho- 
bia), 129. 
Hysteria,  164. 

distinguished     from 
neurasthenia,  136. 
Hystero-epilepsy,  164. 

Idiosyncrasies  in  regard  to  food 

and  medicine,  89. 

Impotence,  partial  or  complete, 
100. 

Insomnia,  69-236. 

Inebriety,  165. 

Insanity  (melancholia),  164. 

Irritability  of  prostatic  ureth- 
ra, 100. 

Irritable  heart,  84. 

Isolation  and  rest,  182. 

Itching,  97. 

Koumiss,  202. 

Laughing  gas,  230. 

Lithaemia,   distinguished  from 

neurasthenia,  138. 
Loins  and  limbs,  82. 
Lomi  Lomi,  216. 

Macrotin,  197. 

Malarial  neurasthenia,  134. 

Massage,  212. 

Meconism  (opio-mania),  166. 

Melancholia,  164. 


INDEX. 


253 


Men,  diseases  of.  100. 
Mental  control,  deficient,  46. 

depression,  48. 

therapeutics,  189. 

irritability,  48. 
Metal  therapeutics,  227. 
Metalloscopy,  227. 
Milk  diet,  180. 
Monophobia,  60. 
Morbid  fears,  50. 
Mountain  air  vs.  sea  air,  249. 
Muscte  volitantes,  43. 
Myelasthenia,  147. 

active     exercise 
in,  149. 
Mysophobia,  62. 

Nature  anci  diagnosis  of  neuras- 
thenia, 118. 
Nerve  alteratives,  231. 
Nervous  chills,  99. 

diathesis,  128. 
diseases,      brain-work 
in,  187. 

climatology 

of,  244. 

of  America 

and     F^u- 

rope,  249. 

dyspepsia     (dyspepsie 

asth6iii<iue),  72. 
exhaustion,  treatment 
of.  176. 
Neuralgia.  165. 
Neuralgias,  97. 

Neuraathenia,     frequency     of, 
111. 

hemi,  106. 
mulurial,  i:V4. 
prognosis      ainl 
sequences     of, 
160. 
time  of  life  most 
frequent,  110. 


Neurasthenic  asthenopia,  42. 
Nitrous  oxide,  230. 
Noises  in  the  ears,  44. 
Numbness  and  hypersesthesia, 
93. 

Opio  mania,  166. 
Opium,  200. 
Oxalates  in  urine,  102. 
Oxaluria,  102. 

Pain,  relief  of,  239. 
Pains  simulating  ataxy,  83, 
Palpitation  of  heart,  84. 
Pantophobia,  61. 
Paralysis,  100-172. 
Pathology  and  rationale,  150. 
Pathophobia,  60. 
Phobophobia,  61. 
Phosphates,  202. 

in  urine,  102. 
Podalgia  (pain  in  the  feet),  83. 
Prognosis  and  sequences.  160. 
Prostatic  urethra,  100. 
Pruritus,  97. 

Pulse  and    palpitation  of  the 
heart,  84. 

Rationale    and     pathology    of 

neurasthenia,  150. 
Rectal  alimentation,  179. 
Rellex  activity  increased,  125. 
Reflexes,  vaso-motor,  151. 
Reproductive  organs,  diseases 

of,  16H. 
Rest  and  isolation,  182. 

ctire.  IHl. 
RluMiinatism.  147. 
Russian  baths,  218. 

Salivation,  79. 

Sandwich    Islands,  climate  of, 

246. 
Sea  air  rn.  mountain  air,  247. 
Seclusion,  186. 


254 


INDEX. 


Sedation,  mental  and  physical, 

234. 
Sensitiveness    to    cold    or  hot 
water,  92. 

weather,  92. 
Sequences  of  neurasthenia,  234. 

treatment  of,  234. 
Sick  headache,  40. 
Siderodromophobia,  62. 
Sleep,  improvement  in,  235. 
Sleeplessness,  69-236. 
SouHiambulism,  172. 
Spasms  of  muscles  (tremors),  87. 
Spermatorrhoea,  102. 
Spermatozoa  in  the  urine^  102. 
Sphygmograph,  85. 
Spinal  anaemia,  131. 

cord,  disease  of,  172. 
exhaustion,  147. 
irritation,    hypersesthe- 
sia,  general,  79. 
Strychnia,  200. 
Sunstroke  an  exciting  cause  of 

neurasthenia,  93. 
Swallowing,  difficulty  of,  88. 
Sweating  hands  (palmar  hyper- 

idrosis),  77. 
Switzerland,  climate  of,  248. 
Symptoms,  correlation  of.  115. 
course  and  caprice 

of,  107. 
multitude  of,  114. 
of  nervous  exhaus- 
tion, 34. 
periodical    charac- 
ter of,  116. 
recovery  of,  161. 
Syphilis     distinguished     from 
neurasthenia,  146. 

Tea  tasting,  198. 
Teeth,  decay  and  irregularities 
of,  105. 

tenderness  of,  72, 


Tenderness  of  the  scalp,  38. 
spine,  79. 
teeth      and 
gums,  72. 
Therapeutics,  mental,  189. 
Thirst,  deficient,  74. 
Ticklishness,  97. 
Tinnitus  aurium,  20. 
Topophobia,  54. 
Trance,  172. 

Travelling  as  medicine,  240, 
Tremors,  87. 
Treatment,  local,  231. 

modes  of,  176. 
of  nervous  exhaus- 
tion, 176. 
of  sequences,  234. 
persistence  in,  233. 
philosophy  of,  231. 
sedative  and  tonic 
effects  of,  234. 
Turkish  baths,  218. 

Urates  in  urine,  102. 
Urethra,  prostatic,  100. 
Urine,  oxalates  and  spermato- 
zoa in,  102. 

Vacations,  short,  242. 
Yaso-motor  reflexes,  151, 
Voice,  atonic,  45. 

Wakefulness,  69,  236. 

White   Mountains,  climate  of, 

248. 
Women,  diseases  of,  101. 
Work  cure,  181. 
Working  order,  163. 
Writer's  cramp,  171, 

Yawning,  103. 

Youth,  appearance  of,  104. 

Zinc,  196, 


SEXUAL  NEURASTHENIA 

^^  ■■  ^  m  ^m  r^  mmi       (nervous  exhaustion.) 
Its  Hygiene,  Causes,  Symptoms  and  Treatment, 

WITH  A  CHAPTER  ON 

By  Ceorgb  M«  Beard,  A.M.,  M.D., 

Foroerly  Lecturer  on  Nervou"  Diseases  in  the  University  of  the  City  of  New  York', 

Fellow  ot  the  NewYork  Academy  of  Medicine:  Author  of  **  Out 

Home  Physician,"  "Hay  Fever;"  one  of  the  Authors  of 

*'  Medical  and  Surgical  Electricity,"  etc 

[pOSTHtJMOfS  MANUSCRIPT.] 

Edited  by  A.  D.  Rockwell,  A.M..  M.D. 

0aBam  of  the  New  York  Academy  of  Medicine^  and  Electro* Therapeutist  to  the 

a,  Yt   Stato  Woman's  Hospital;  one  of  the  Authors  of  '  Medical 

and  Surgical  Electricity,"  etc 

The  pMloSOpliy  of  tllis  VOrk  is  based  on  the  theory  that  there  is 
a  special  and  very  important  and  very  frequent  clinical  variety  of  neuras- 
thenia (nervous  exhaustion)  to  ^vh:ch  the  term  sexual  neurasthenia 
(sexual  exhaUBtion)  may  properly  be  ap  phed. 

While  ihis  ^.-lriety  may  be  and  often  is  involved  as  cause  or  effect 
«r  coincident  with  other  varieties — exhaustion  of  the  brain,  of  the  spine, 
of  the  stomach  and  digestive  system — yet  in  its  full  development  it  can 
be  and  should  be  difieientiated  from  hysteria,  simple  hypochondria,  in- 
sanity, and  various  organic  diseases  of  the  nervous  system,  with  all  of 
which  it  had  until  lately  been  confounded. 

The  long  familiar  local  conditions  of  genital  detility  in  the  nialw> 
—impotence  and  spermatorrhoea,  prostatorrlioca,  irritable  prostate— 
which  have  hitherto  been  almoit  universally  described  as  diseases  by 
themselves,  are  philosophically  jrnd  clinically  analyzed.  These  symp- 
toms, as  such,  do  not  usually  exist  alone,  but  are  associated  with  other 
local  oi  general  symptoms  of  sexual  neurasthenia  herein  described. 

ThO  OiUSea  of  sexual  neurasthenia  are  not  single  or  simple  but 
complex;  evil  habits,  excesses,  tobacco,  alcohol,  worry  and  special  ex- 
citements, even  climate  itself,  are  the  great  predisposing  causes. 

The  subject  is  restricted  mainly  to  sexual  exhaustion  aS  it  OZistS  in 
tho  xnald,  for  the  reason  that  the  symptoms  <  f  neurasthenia,  as  it  exists 
b  females,  are,  and  for  along  time  have  been,  u:>derstood  and  lecog- 
nized.  Cases  analogous  to  those  in  females  arc  dismissed  as  hypochon- 
driacs, just  as  females  sufTerin.;  from  now  clearly  explained  uterine  and 
ovarian  disorders  were  formerly  dismissed  as  hysterics. 

This  view  of  the  relation  of  thO  reproductive  fiystenx  to  nervous 
diseases  is  in  accordance  with  facts  tliat  are  verifiable  and  abundant; 
that  in  men  as  in  w  >mcn,  a  large  group  of  nervous  symptoms,  which  arc 
Tery  common  indeed,  would  not  exist  but  for  morbid  slates  of  the  re- 
productive system. —  [From  Dr.  Bi.\i' d' s  JntroJucttou. 

The  Causes  and  Symptoms  of  forty-three  cases  arc  given,  foU 
Jowed  by  a  chapter  on  treatment. —  \,^e  Review  of  ::it.  Louis  Ntuional 
J^ruggist  and  others. 

In  One  Volume,  Crown  8vo,  Nearly  300  pares,  $2< 

ijfints  Wantel        E.  B.  TREATJ'ub.,  771  Broaciwa),  N.  Y. 


THE  NEW  CYCLOPEDIA  OF  FAMILY  MtOiCINE. 


A  NEW  AND  POPULAR  GUIDE  TO  THE 

Art  of  Preserving  Health  artd  Treating  Disease  ;  vrith 

Plain  Advice  for  all  the   Medical  and  Surgical 

Emergencies  of  the  Family.     Based  on  the 

most  Recent  and  the  Highest  Authorities, 

and  brought  down  to  the  Latest  Dates. 

By  GEO.  M.  BEARD,  A.M.,  M.D. 

Formerly  Lecturer  on  Neivous  Diseases  in  the  University 
of  New  York  ;    Fellow  of  the  New  York  Academy  of 
Medicine  ;    Member  of  the  New  York  County  Medical 
Socieiy,  etc. 
Assisted  in  its  Several  Departments,  as  follows  : 

Diseases  of  the  Eye  and  Ear,  by  D.  B.  St.  JOHN  ROOSA,  M.D., 

Prisidetit  Ntiu  York  Post  Graduate  Medical  School. 
Diseases   of  tlie   Skin,    by  GEO.  HENRY    FOX,  M.D.,     Professor  of 
Skin  Diseases,  College  of  Physicians  and  Surgeons.,  New  York. 

Diseases  Of  Women  and  Children,  by  j.  B.  hunter,  m.d.,  Surgeon 

to  the  Aew  )  ork  State  \Vomans  Hospital. 
Surgery,  by  BENJAMIN  HOWARD,  M.D.,  formerly   Professor  in 

the  L.  I.  College  Hospital,  Brooklyn. 
Dental  Surgery,    by  N.  W.  KINGSLEY,  M.d.,   Dean   of  New    York 

Colle-'e  o  '  Dentistry . 
Materia  Medica,  by  LAURENCE  JOHNSON,  M.D.,   President  of  the 

vVVu'  )'(7r/f-  County  Medical  Society . 
General   Eevision,    by  A.  D.   ROCKWELL,    M.D.,    Electro- Therapeu- 
tist to  tne  Neiu  York  State  PYoman's  Hospital. 
Ind  upwards  of  170  other  widely  known  American  and  European  authorities, 
With  an  appendix  giving 
Homoeopatbtc  Reiupdies  and  Treatment.    By  SAM- 
UEL  LILIENTHAL,  M.D.,  Projessor  in  the  New  York  Homoe- 
opathic College,  Editor  of  the    "  North   American   journal  of 
Homoeopathy,^^  etc. 

It  is  written  for  the  people,  in  plain,  common-sense  language,  giv- 
ing causes,  symptoms,  and  reliable  remedies  for  every  ill.  ]ts  ever- 
ready  counsel  will  dispel  anxious  fears,  doubts,  and  uncertainties,  and 
will  prove  a  Good  Samaritan  in  every  family  that  has  it,  in  promoting 
health,  happiness,  and  long  life. 

Over  1500  Royal  Octavo  Pages.  Illustrated  with 
nearly  400  Chromo  Plates  and  Wood  Cuts,  carefully  excluding  such 
as  would  offend  good  taste  and  propriety.  AGENTS  WANTED. 

■"V^rilSTri.""-  Reduced  lo  IC,  Full  Shsep,  J?  50. 

E.  B.  TREAT,   Publisher,  771  Broadway,  N.  Y, 


ilES 


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*•     .' 


!■■ 


Annex 


